
Class __________ 



GopyiightN^, 



^ r.C. 



COPYRIGHT DEPOSm 



THE DISEASES 



OP 



INFANCY AND CHILDHOOD. 



DESIGNED FOR THE USE OF 



STUDENTS AND PRACTITIONERS OF MEDICINE, 



BY 

HENRY KOPLIK, M.D., 

ATTENDING PHYSICIAN TO THE MOUNT SINAI HOSPITAL ; FORMERLY ATTENDING PHYSICIAN 
TO THE GOOD SAMARITAN DISPENSARY, NEW YORK ; EX-PRESIDENT OF THE AMERICAN 
PEDIATRIC SOCIETY ; MEMBER OF THE ASSOCIATION OF AMERICAN PHYSI- 
CIANS, AND OF THE NEW YORK ACADEMY OF MEDICINE. 

SECOND EDITION, THOROUGHLY REVISED AND ENLARGED. 

ILLUSTRATED WITH 184 ENGRAVINGS AND 33 PLATES IN 
COLOR AND MONOCHROME. 




LEA BROTHERS & CO., 

NEW YORK AND PHILADELPHIA, 

1906 



LIBRARY of CONGRESS 
Two Copies Received 
JAW 24 1906 

CoDyright Entry 
/ ^LASS CC XXc. No 






(3 



Entered according to Act of Congress, in the year 1906, by 

LEA BROTHERS & CO., 

In the Office of the Librarian of Congress. All rights reserved. 



WESTCOTT & THOMSON, 
ELECTROTYPERS, PHILADA. 



WILLIAM J. OORNAN, 
PRINTER, PHILADA. 



THIS WORK 

IS INSCRIBED TO MY PRECEPTORS, 

FRANCIS DELAFIELD, M. D., LL.D., 

EMERITUS PROFESSOR OP THE PRACTICE OF MEDICINE IN THE COLLEGE OF 
PHYSICIANS AND SURGEONS, COLUMBIA UNIVERSITY, NEW YORK, 

AND 

MATHEW D. MANN, M. D., 

PROFESSOR OF OBSTETRICS AND GYNiECOLOGY IN THE UNIVERSITY 
OF BUFFALO, NEW YORK. 



PREFACE TO THE SECOND EDITION. 



The preparation of this edition has given the author an oppor- 
tunity of bringing the work abreast of the advances of the past few 
years. To this end the various sections of the book have been 
revised — some of them entirely rewritten. The section on Infant- 
feeding has been remodeled so as to give those methods which are 
practical and which can be readily carried out by the practitioner. 

Merely theoretical and impractical matters (in which the litera- 
ture of pediatrics, unfortunately, abounds) have been carefully 
avoided, as out of place in a treatise designed for the student and 
practitioner. 

It has also seemed to the author desirable to give a more complete 
account of the Physiology and Pathology of the Newborn than is 
customary ; in this section, therefore, the writer has gone into 
greater detail than hitherto. 

The section treating of The Specific Infectious Diseases has 
received extensive additions ; some of the articles, such as those on 
Typhoid Fever, and Meningitis, having been completely recast in 
accordance with accumulating experience and the latest advances. 
New illustrations (from original drawings) and additional charts 
have been liberally introduced wherever it was thought they could 
be of service. 

In the general plan and clinical character of the work the original 
purpose of the author — to present a succinct reflection of the pediatric 
practice and knowledge of the day — has been kept prominently in 
mind. To his publishers the author wishes to return thanks for 
their liberality. To Dr. Herman Schwarz thanks are due for valu- 
able aid and suggestions. 

H. K. 

New York, 1906. 



CONTENTS. 



SECTION I. 

INFANCY AND CHILDHOOD. 

PAGE 

I Definition of infancy and childhood. II. Morbidity : The newborn infant — 
Childhood. III. Mortality. IV. Sudden death among infants and children. 

V. The normal infant and child : body-weight ; length of body ; head — 
Respiratory functions : the shape of the chest ; chest circumference ; normal 
number of respirations ; chemism of respiration — Circulation and pulse : 
pulse rapidity ; rhythm of pulse — Body-temperature : heat calories — Urine : 
physical characteristics ; daily quantity ; urea : daily amount ; albumin, 
indican, acetone, diacetic acid, urobilin, dextrose, casts, uric acid infarction. 

VI. Mental and physical development of the infant ; sight ; hearing ; taste ; 
feelings of pleasure; power to hold the head upright; sitting; standing; 
ci"awling and walking ; laughing ; kissing ; memory ; speech. VII. Methods 
of examination ; taking a history ; taking the status prsesens — The head — 
The face : in cardiac disease ; facial paralysis ; nuclear palsy ; Basedow's dis- 
ease ; hydrocephalus; rachitis; exhausting diseases; congenital syphilis; 
the palpebral fissure — Sight : photophobia ; nystagmus — Physical examina- 
tion of the chest : position of the patient ; instruments used ; methods of 
procedure ; inspection, the cardiac area, palpation, percussion — The abdo- 
men : inspection, peritonitis ; tumors ; palpation : ascites ; tympanites ; pain ; 
rectal exploration — Examination of the joints : joint crepitus — The spine : 
method of examination — Muscular apparatus and nervous system : atrophy; 
hypertrophy ; patellar reflex ; Babinski reflex ; Kernig's symptom ; gait or 
walk ; ataxic gait, cerebellar titubation, spastic walk, limping gait, infantile 
paralysis. VIII. Management and hygiene of the normal infant : taking 
the infant from the mother at birth ; tying of the cord ; daily bath ; stump 
of the cord ; first bath ; premature infants and infants who are under- 
weight ; hardening ; eyes ; method of taking the body-temperature of the 
infant ; diapers ; care of the genitalia ; play ; fondling ; sleep ; bed ; nursery ; 
open air ; clothing ; body-binder ; skin ; mouth. IX. The administration 
of drugs and other methods of therapy : hyperdermoclysis — Hydrotherapy : 
the sponge bath ; cold chest compress ; the cold pack ; the full bath — 
Syringing the nose — Vapor spray ; calomel inhalations in acute laryngeal 
disease— Stomach washing — Gavage — Rectal enemata ; enteroclysis . . . 17-70 



vu 



Viu CONTENTS. 

SECTION 11. 

INFANT-FEEDING. 

PAGE 

I. The principles underlying the processes of nutrition — Water — Mineral salts — 
Proteids — Fats — Carbohydrates. II. Metabolism in the nursing infant — 
Mineral salts — Excreta — Water— Carbonic acid gas — Metabolism in the 
bottle-fed infant. III. The food of the infant — Human-breast milk : colos- 
trum ; physical properties ; milk : composition, proteids, fats, mineral salts 
in the milk, reaction, specific gravity ; bacteria in the breast milk ; enzymes 
and alexins of human milk ; amount of breast milk consumed by the infant 
in twenty-four hours ; changes in the composition of milk ; daily changes ; 
influence of foods on breast milk ; drugs and foreign substances in the milk ; 
passage of bacteria of the infectious diseases into the breast milk ; toxins ; 
antitoxins and agglutinins ; menstruation ; pregnancy — Methods of analysis 
of human milk : specific gravity ; fat ; Lewi's method ; the proteids — Cows' 
milk : composition : fat, proteids, casein ; bacteria in cows' milk : Pasteur- 
ization, sterilization ; infected cows' milk as a cause of epidemics : typhoid 
fever, dysentery, diphtheria, scarlet fever, cholera Asiatic, tuberculosis ; 
milk acidity ; what shall the practitioner do in regard to sterilization and 
Pasteurization ? — Kaw milk in infant-feeding — Frozen milk — Nursing bot- 
tles ; Pasteurization ; sterilization. IV. Food preparations : peptonized 
milk— Barley water ; oatmeal gruel ; arrowroot gruel ; beef juice; peptone 
preparations ; kumyss ; beef extracts ; beef broth ; acorn cocoa. V. Artificial 
infant foods : composition of infant foods. VI. Maternal nursing : contra- 
indications to maternal nursing — Selection of a wet-nurse — Quantity of the 
milk — Care of the breast : fissured nipples ; caking of the breast, nursing the 
infant ; signs of efficient breast-feeding ; signs of inefficient breast-feeding. 
VII. Mixed feeding. VIII. Artificial feeding of infants : Biedert's mixture ; 
the Kotch method, principles underlying the Rotch method : proteids, fats, 
sugar, salts ; a schedule of percentages adapted to infants of various ages ; the 
number of nursings with the necessary quantity of milk to be fed to the in- 
fant ; number of nursings daily with the necessary quantity of each feeding 
for the artificially fed infant ; table — Household modification of milk for 
infant-feeding: top milk : twelve per cent, top milk, seven per cent, top milk 
— Top milk made at home ; clean milk — Home preparation or modification of 
milk for infant-feeding — Method of calculating percentages of fat, proteids, 
and sugar — Too high fat-percentages and their remedy : diluents ; reaction 
— When is a bottle-fed infant thriving? — Spitting; colic; fat-diarrhoea; 
green movements — Disturbances in the bottle-fed infant which are on the 
boundary line between the normal and abnormal, vomiting: stationary 
weight, too low a percentage of fats ; assimilation of the food without in- 
crease in the weight — When shall the food be peptonized? — Whey method 
of modification of cows' milk. IX. When shall the physician resort to 
infant foods- -Barley gruels and how to utilize them — Dextrinized gruels as 
infant food. X. Food of the breast-fed or bottle-fed infant after the sixth 
month. XI. Feeding from the ninth to the twelfth month. XII. Feeding 
from the twelfth to the eighteenth month. XIII. Schedule of feeding from 
the twelfth to the eighteenth month. XIV. Feeding from the eighteenth 
month to the end of the second year — The feeding of sick infants and 
children 71-156 



CONTENTS. ix 

SECTION III. 
DISEASES OF THE NEWBOKN. 

PAGE 

I. Physiology of the newborn — Respiration — Circulation — Pulse — Blood — Di- 
gestive functions — Body temperature — Skin — Breasts — Urine — Kectal Ex- 
creta — Nervous system — Metabolism — Excretion and waste. II. Mortality 
and sudden death in the newborn. III. Congenital anomalies — Of the 
scrotum — Testes— Hydrocele congenita or adnata. IV. The congenitally 
weak (premature infants) — Management of congenitally weak infants : 
incubators — Bath and clothing of the congenitally weak — Ultimate fate of 
the incubator infant — Feeding of the congenitally weak and premature 
infants. V. Asphyxia of the newborn infant. VI. Asphyxia subsequent 
to birth. VII. Atelectasis of the lungs. VIII. Septic infection of the 
newborn infant. IX. Diseases of the umbilicus — Omphalitis — Umbilical 
fungus — Blenorrhoea of the umbilicus— Phlegmon of the umbilicus — Ulcer 
of the umbilicus — Gangrene of the umbilicus — Erysipelas of the umbilicus 
— Infection of the umbilical vessels — Phlebitis umbilicalis — Hemorrhage 
from the umbilicus— Idiopathic hemorrhage from the umbilicus — Umbilical 
hernise. X. Peritonitis of the newborn. XI. Tetanus of the newborn in- 
fant. XII. Icterus in the newborn infant. XIII. The occurrence of hem- 
orrhage in the newborn. XIV. Melsena neonatorum. XV. Acute fatty 
degeneration of the newborn. XVI. Winckel's disease. XVII. Sclerema. 
XVIII. Ophthalmia neonatorum. XIX. Caking of the breasts. XX. Mas- 
titis. XXI. Injuries inflicted during birth 157-229 

SECTION IV. 

THE SPECIFIC INFECTIOUS DISEASES. 

The Exanthemata — I. Scarlet fever. II. Rotheln. III. Measles. IV. Vari- 
cella. V. Vaccination — Other specific infectious diseases. VI. Typhoid fever. 
VII. Malarial fever. VIII. Influenza. IX. Glandular fever. X. Menin- 
gitis — Cerebrospinal meningitis — Acute lepto meningitis. XI. Posterior 
basic meningitis. XII. Meningitis serosa. XIII. Mumps. XIV. Pertussis 
convulsiva. XV. Diphtheria — Diphtheroid. XVI. Scrofula. XVII. 
Tuberculosis : foetal tuberculosis — Pulmonary tuberculosis — Tuberculosis 
of the peritoneum; other forms of tuberculosis (larynx; pleura; peri- 
cardium ) — Abdominal tuberculosis — Tuberculous meningitis — Tuberculosis 
of the brain. XVIII. Syphilis : Acquired syphilis — Late hereditary syph- 
ilis — Congenital or hereditary syphilis. XIX. Acute articular rheumatism 
— Other forms of so-called rheumatism — Muscular rheumatism .... 231-421 

SECTION y. 

DISEASES OF THE DIGESTIVE SYSTEM. 

I. Diseases of the mouth : physiological facts ; physiology of the act of 
nursing ; characteristics of the normal mouth — Normal dentition — Ab- 
normal dentition — Pathology of dentition — Ulcerations or erosions of the 
angles of the mouth — Bednai-'s aphthae — Sprue — Aphthous stomatitis— 



CONTENTS. 

PAGE 

Toxic stomatitis — Ulcerative stomatitis — Gonorrheal infections of the 
mouth — Pseudodiphtheritic stomatitis — Noma. II, Diseases of the tongue 
— Congenital anomalies of size — Ringworm — Desquamation ; tongue-swal- 
lowing ; tongue-tie. III. Malformations of the uvula. IV. Diseases of the 
oesophagus—Congenital anomalies : branchial fistulse ; diverticula ; stricture ; 
atresia or absence of the oesophagus — OEsophagitis — Perioesophageal abscess. 
V. Diseases of the stomach and intestines — Classification ; stomach 
anatomy ; capacity ; marking out the stomach by percussion ; function and 
motility ; acids of the stomach ; stomach digestion ; intestinal digestion — 
Characteristics of the stools of normal infants — Acute gastric dyspepsia — 
Habitual vomiting of infants : cyclic vomiting — Colic — Tympanites — Dila- 
tation of the stomach — Ulcer of the stomach — Hypertrophic pyloric ste- 
nosis — Acute gastro-enteritis (cholera infantum) — Infantile atrophy— 
Acute and subacute enterocolitis — Dysentery — Amoebic dysentery — Consti- 
pation in infants and children — Congenital dilatation of the colon — Appen- 
dicitis — The rectum : prolapsus ani ; fissure of the anus ; spasms of the 
anus — Proctitis — Polypus of the rectum — Intestinal parasites. VI. Dis- 
eases of the liver — Anatomical examination — Tumors or conditions simu- 
lating enlargement of the liver— Jaundice — Congenital obstruction of the 
bile-ducts — Cirrhosis of the liver — Fatty degeneration of the liver — Syph- 
ilis of the liver — Abscess of the liver — Acute yellow atrophy of the liver. 
VII. Diseases of the peritoneum — Ascites — Acute peritonitis— Gonococcal 
peritonitis— Pneumococcal peritonitis — Simple chronic peritonitis . . 422-525 

SECTION VI. 

DISEASES OF THE RESPIRATORY SYSTEM. 

Diseases of the Nose and nasopharynx — Acute nasal catarrh — Chronic 
nasal catarrh— Diphtheritic rhinitis — Foreign bodies in the nose — Epistaxis 
— Adenoid vegetations — Acute retropharyngeal abscess. II. Diseases of the 
tonsils — Acute follicular amygdallitis— Herpes of the tonsils— Ulceromem- 
branous tonsillitis. III. Diseases of the larynx— x-Vcute catarrhal laryngitis 
— CEdema glottidis—Syphilis of the larynx— Tuberculosis of the larynx- 
Growths in the larynx— Foreign bodies in the larynx. IV. Diseases of the 
bronchi — Acute simple bronchitis— Fibrinous or plastic bronchitis — Em- 
physema and chronic bronchitis — Bronchiectasis. V. Diseases of the lungs 
—General considerations ; movements of the chest ; normal limits of the 
lung; resiliency of the chest wall; percussion; auscultation; types of 
breathing; forms of dyspnoea— Pneumonia— Lobar pneumonia— Broncho- 
pneumonia — Persistent bronchopneumonia. VI. Diseases of the pleura — 
Pleurisy— Dry pleurisy — Pleurisy with effusion and empyema — Hemor- 
rhagic pleurisy and empyema — Subphrenic abscess 526-623 



SECTION YII. 

DISEASES OF THE CIRCULATORY SYSTEM. 

I. Pericarditis -Adherent pericardium. 11. Diseases of the heart— Heart ; posi- 
tion; size; apex beat; examination of the heart— Congenital heart dis- 



CONTENTS. xi 

PAGE 

ease — Stenosis of the pulmonary artery, conus or ostium— Open ductus 
arteriosus — Congenital septum defects — Maladie de Koger — Acute endo- 
carditis — Septic endocarditis — Chronic valvular disease of the heart — 
Cardiac murmurs — Accidental cardiac murmurs — Myocarditis — Hyper- 
trophy and dilatation of the heart 624-660 

SECTION yiii. 

CONSTITUTIONAL DISEASES. 

I. Kachitis. II. Kheumatoid arthritis. III. Chondrodystrophia fcetalis. IV. 

Osteogenesis imperfecta. V. Diabetes mellitus. VI. Diabetes insipidus 661-684 

SECTION IX. 

DISEASES OF THE LYMPH-NODES, DUCTLESS GLANDS, 
AND THE BLOOD. 

I. Diseases of the lymph-nodes — Acute adenitis — Chronic lymphadenitis. 
II. Diseases of the thyroid gland — Enlargements of the thyroid— Cre- 
tinism, endemic and sporadic. III. Diseases of the thymus : landmarks ; 
weight — Percussion — X-ray — Hypertrophy of the thymus; status lym- 
phaticus ; thymus death. IV. Diseases of the spleen : anatomical — Ex- 
amination of splenic and kidney tumors. V. Diseases of the blood — Leading 
characteristics in infancy and childhood; the red blood-cells; the white 
blood-cells ; the haemoglobin ; the specific gravity — Anaemia — Simple anaemia 
— Chlorosis — Pseudoleuksemic anaemia of von Jaksch — Leukaemia — Acute 
leukaemia — Chronic leukaemia — Hodgkin's disease — Hemorrhagic diathesis 
— Simple purpura — Haemophilia — Purpura haemorrhagica — Purpura rheu- 
matica — Henoch's purpura — Pernicious anaemia — Infantile scorbutus or 
scurvy. VI. Diseases of the suprarenal bodies— Addison's disease . . 685-728 

SECTION X. 

DISEASES OF THE BONES. 
General facts — Acute infectious osteomyelitis 729-732 

SECTION XL 

DISEASES OF THE EAR. 
Otitis in infancy and childhood— The mastoid 733-740 

SECTION XII. 

DISEASES OF THE KIDNEYS AND UEOGENITAL TRACT. 

General anatomy — Floating kidney — Cyclic albuminuria — (Edema and hydi-ae- 
mia without kidney lesion — Dysuria — Haematuria — Haemoglobinuria — Renal 
calculi — Acute nephritis — Chronic difiuse nephritis — Growths of the kid- 
ney — Cysts; hydronephrosis ; sarcoma ; carcinoma — Tuberculosis; pyelitis; 
peri- and para-nephritis ; enuresis ; nocturna and diurna — Vulvovaginitis — 
Urethritis in male children— Cystitis— Bacteriuria 741-765 



xii CONTENTS. 

SECTION XIII. 
DISEASES OF THE NERVOUS SYSTEM— METHODS OF DIAGNOSIS. 

PAGE 

Lumbar puncture — Normal cerebrospinal fluid : abnormal conditions ; the spe- 
cific gravity ; the gross appearances ; tuberculous meningitis ; suppurative 
meningitis ; epidemic and sporadic cerebrospinal meningitis ; chronic hydro- 
cephalus ; the sediment ; the pressure — The operation of lumbar puncture 
— Infantile convulsions — Hysteria — Tetany — Catalepsy — Myotonia — Con- 
genital stridor of infants — Laryngismus stridulus — Epilepsy — Pavor noc- 
turnus — Chorea — Chorea insaniens — Forms of tic — Rhythmic movements 
of the head associated with nystagmus— Hydrocephalus — Chronic internal 
congenital hydrocephalus — External hydrocephalus — Amaurotic idiocy — 
Tumors of the brain — Infantile cerebral palsy — Facial palsy — Multiple 
neuritis — Erb's palsy — Hereditary ataxia — Acute atrophic paralysis — 
Juvenile form of progressive muscular atrophy — Landouzy's form of mus- 
cular atrophy — Pseudohypertrophic muscular paralysis — Deformities of the 
skull and spinal canal — Spina bifida 767-836 

SECTION XIV. 

DISEASES OF THE SKIN. 

General facts — Eczema — Erythema multiforme — Furunculosis — Sudamina 
— Dermatitis exfoliativa — Congenital ichthyosis — Pemphigus neona- 
torum 837-848 



DISEASES OF INFANCY AND CHILDHOOD, 



SECTION I. 

INFANCY AND CHILDHOOD. 
I. DEFINITION OF INFANCY AND CHILDHOOD. 

Infancy, or the nursing age, is the period of life during which 
the child is at the breast. It extends from birth to the twelfth 
month. 

Childhood is the succeeding period, extending to puberty. In 
addition, it is customary to divide the period of childhood into two 
parts — the first extending from the end of the first to the sixth or 
seventh year, or the beginning of the second dentition ; the second, 
from this to puberty. 

Epstein would include as newborn all infants up to the third 
month. 

II. MORBIDITY. 

The Newborn Infant. — The diseases of the newborn infant are, 
for the most part, septic in nature, and attack the infant within a 
short time after birth. 

Conditions favor the diseases common at this time of life. The 
skin is not fully formed, is in process of desquamation, and bacteria 
easily gain access to the circulation. The umbilicus is an open 
wound, receptive of infection. The mucous membranes of the in- 
testine, mouth, eye, and ear are other avenues of entrance for bacteria. 
There is a tendency for minor infections to become general at this 
period. The artificially fed infant is, in addition, exposed to the 
dangers which necessarily accompany the introduction into the body 
of a foreign food with its attendant uncleanliness, and is also deprived 
of the protective bodies (alexins) contained in the mother's milk. 
With new surroundings, in a new atmosphere, with new appliances 
for maintaining the body-heat (such as the clothes), and with careless 
handling, it is obvious that the newborn infant is peculiarly exposed 
to bacterial diseases. 

Childhood. — If we study the statistics of any large pediatric 
clinic, it will at once be apparent that up to the tenth year of life 
2 17 



18 INFANCY AND CHILDHOOD. 

those diseases which affect the respiratory apparatus form nearly 
two-fifths of the cases. Next in order of frequency are the diseases 
of the digestive tract ; and, lastly, the acute infectious diseases, such 
as the fevers and exanthemata. Of 53,040 cases met with during 
five years in an ambulatory clinic, there were 20,207 cases of dis- 
eases of the respiratory organs, 17,058 of the gastro-enteric tract, 
and 2409 of the acute infectious diseases. If the morbidity is 
analyzed still further, it is seen that in the nursing period intestinal 
disturbances are the most frequent. The numerous flora of bacteria 
and their toxins in the intestine of the infant rather predispose to 
infections from that source. These bacteria may invade the mucous 
membrane of the intestine, and in certain disturbances of the func- 
tions of the gut obtain access to the circulation. The respiratory 
diseases become more frequent in the second year, and reach their 
maximum frequency between the second and third years. Constitu- 
tional diseases, such as rachitis, appear in the second half-year of 
life, and reach their greatest frequency during the period from the 
tenth to the fifteenth month. On the other hand, the acute infec- 
tious diseases, such as the exanthemata, are more common from the 
fifth to the eighth year. Scarlet fever, with its kidney complica- 
tions, is most frequent at the fourth year (Escherich), diminishing 
at the ninth year. The period extending from the second to the 
fourth year is also notable for the frequency of the so-called " filth 
infections '' of Feer. Children infect themselves with dirt and 
dust at play, at meals or in their intercourse with one another. 
For this reason, diphtheria as well as pertussis and tuberculosis 
(Escherich) attain their maximum frequency at this period. 

III. MORTALITY. 

The mortality of infants is large, and is highest among the poor 
of cities of the first magnitude. With the well-to-do, artificial 
feeding is resorted to for social reasons ; among the poor, a mother 
who is forced to work is compelled to deny the breast to her child. 
The vast majority of deaths occur among the artificially fed infants 
in all countries. In England fully two-fifths of the whole number 
of deaths occur before the tenth year ; one-fourth occurring before 
the termination of the first year of life. These figures, given by 
Williams, correspond quite closely to those of Eross, of Germany, 
and to what is known to be true of America. The mode of living 
among the poor, and the lack of complete, or even partial, isolation 
in contagious diseases, tend to increase this great mortality among 
infants and children. 

The following table was furnished to the author by the New 
York Board of Health, and shows at a glance the death-rate among 
infants and children at various ages : 



SUDDEN DEATH AMONG INFANTS AND CHILDREN. 



19 



Year. 


Under one year. 


One year to five 

years. 


Five to ten years. 


Ten to fifteen 
years. 


Deaths. 


Death- 
rate. 


Deaths. 


Death- 
rate. 


Deaths. 


Death - 
rate. 


Deaths. 


Death- 
rate. 


1900 . . 

1901 . . 

1902 . . 


16,640 
15,467 
15,526 


191.7 
173.6 
164.8 


9196 

8789 
8862 


29.e54 
27.49 
26.27 


2073 
2130 
2065 


5.86 
5.87 
5.39 


863 
904 

889 


2.86 
2.92 

2.72 



The death-rate per thousand in diarrhoeal disease in old New 
York of infants below a year of age was as follows : 

In 1890 2.55 

In 1891 1.71 

In 1892 1.52 

There has been in New York at least a gradual diminution of 
the death-rate in one of the principal causes of mortality among 
infants. This is quite easily explained by certain conditions which 
obtain to-day and which were absent years ago. Cows^ milk, which 
is the principal food of artificially fed infants, is much improved as to 
quality, through the efforts of the authorities, as compared with the 
standard in vogue some years ago. The establishment, also, of 
milk laboratories for the distribution to the poor of pasteurized or 
sterilized milk in separate nursing portions, and the teaching of 
hygienic measures directed toward the prevention of disease, 
have tended vastly to improve the conditions in this social stratum 
of society. We hardly see to-day, what formerly was quite a 
common sight, a baby fed from one bottle throughout the twenty- 
four hours. Even the lowliest mother to-day understands the 
necessity of cleanliness in the preparation of the infant's food. 
If mothers could be taught more fully methods of prophylaxis and 
hygiene we could still further reduce the death-rate among infants. 



IV. SUDDEN DEATH AMONG INFANTS AND 
CHILDREN. 

In many diseases prevalent among infants and children, sudden 
death is the outcome. In hospital services, at least, it is not 
uncommon for an infant, who is apparently doing well, to be over- 
taken in the next few moments by sudden death. It is not sur- 
prising, therefore, that in New York alone, in the year 1 902, no less 
than 594 infants below the age of one year have been reported to 
the Board of Health as having died suddenly. The total number 
of children dying in this manner in 1902 was 717. These infants 
and children are reported to the Board of Health as dying suddenly 
with or without convulsions. In the first year of life, therefore, 
sudden death is very frequent, and the statistics given by the New 
York Board of Health are confirmed by those of other cities of the 
first magnitude, Richter has recently shown that in Vienna 1797 



20 INFANCY AND CHILDHOOD. 

cases of sudden death occurred during the years from 1897 to 1901 
in children from the first day of life to the fifteenth year; 1525 of 
these deaths occurred in infants below the age of one year. In 
New York we have no autopsy records to show the causes of death 
in the cases reported of infants dying suddenly with convulsions ; 
but Kichter, who has made autopsies in similar cases in Vienna, as 
mentioned above, found that the most frequent cause, in his cases at 
least, of sudden death was acute bronchitis complicated with, or 
without, acute bronchopneumonia. These infants gave few or no 
previous symptoms, such as fever or cough, before the fatal issue. 
At autopsy the bronchi were found plugged with inflammatory 
exudate. The death in these cases is really one of asphyxia com- 
bined with heart failure. The next most frequent cause of sudden 
death was acute intestinal catarrh or diarrhoeal disease. In these 
cases death is caused by auto-intoxication with resultant eclampsia. 
The remaining causes of sudden death were found to be asphyxia, 
caused by vomiting, with consequent aspiration into the trachea of 
food masses, in infants the subject of intestinal catarrh or bron- 
chitis ; tuberculosis, in which a diseased gland may have broken 
into a bronchus ; diphtheria, meningitis, intra-uterine asphyxia, in 
which efforts at resuscitation after birth were interrupted by sudden 
death ; acute bronchopneumonia ; and in older children sudden 
death may have occurred at the outset of an infectious disease. 
Richter found some cases of septicaemia, congenital syphilis, neph- 
ritis, anomalies of the brain or general nervous system, and con- 
genital diseases of the heart. Aside from all the above causal 
agents of sudden death, there remain a few cases, now and then 
reported in the literature, in which sudden death occurs preceded by 
an eclamptic seizure or spasm of the glottis (laryngismus) ; and in 
which post-mortem examination reveals absolutely no change in the 
internal organs to account for the sudden death except an enlarged 
thymus or a lymphatic hyperplasia throughout the body, especially 
in the mucosa of the intestines. This cause of sudden death is 
more fully considered under the head of Status Lymphaticus, but it 
may be stated here that these cases form but a small percentage of 
the cases of sudden death occurring in infants or children in pre- 
vious apparent health. In fact, Richter found that of the 1797 
cases of sudden death of infants and children from birth to the 
fifteenth year, only 1 could be attributed to an enlarged thymus, 
with or without lymphatic hyperplasia. In this he is supported 
by the opinion of those who, from their experience, are competent 
to pass judgment upon this most important question. The physi- 
cian, therefore, confronted with sudden death in a rachitic infant or 
a lymphatic child should be mindful not to attribute this death to 
external influences, but rather to diseased conditions which may be 
present in a particular patient. 



THE NORMAL INFANT AND CHILD. 21 

V. THE NORMAL INFANT AND CHILD. 

A good knowledge of the facts connected with the growth and 
development of the infant and child is essential to the understand- 
ing of diseased conditions in these subjects. Normal children vary 
within certain limits, as to their body-weight, temperature, pulse, 
respiration, and secretion of urine, in a manner similar to sick 
infants in the presentation of symptoms. One child may weigh 
more or less than another of the same age, and still be in excel- 
lent health. The physician must take into account not only the 
infant itself, but conditions of heredity and surroundings. There 
is absolutely no unvarying picture of a normal child. There 
are limits of variation, and these the physician should endeavor 
to master. 

Body-weight. — During the first two or three days following the 
birth of the infant there is a loss of body-weight. Usually this 
loss amounts to from 150 to 200 grammes, or 5 to 6 J ounces (Fig. 
1). It is in some infants even greater. The passage of meconium 
and urine, the exhalations from the skin and lungs, and the small 
amount of nourishment taken by the infant account for this loss. 
As nursing begins the weight increases until the seventh day, when 
the infant, under normal conditions, will have regained its original 
weight. On the tenth day the infant weighs 100 grammes, or 3 J 
ounces, more than it did at birth. 

In some cases, if the infant is placed immediately after birth on 
a breast which secretes milk abundantly, it will not lose any, or but 
little, weight. 

In an investigation by Gundling it was noted that many infants 
ceased to lose in weight after the second day, and an almost equal 
number on the third day. Boys lost more than girls, and the 
infants of multiparse less than those of primiparse. The average 
entire loss, however, was about 241 grammes. Most infants regain 
their original weight on the ninth day. The average infant, accord- 
ing to Camerer, at birth weighs 3450 grammes ; and according to 
Budin there is a physiological loss of the amount indicated above, 
which is rapidly regained from the seventh day on, when the weight 
rises in a physiological curve throughout the remainder of infancy. 

From the second week to the fourth month an infant gains 1 
ounce (30 grammes) daily, or IJ to 2 pounds a month, the latter in 
the first two months ; from the fourth to the sixth month it will gain 
J to f of an ounce daily (17 to 20 grammes), or about a pound a 
month. From the sixth to the twelfth month the infant gains J 
ounce daily (15 grammes), or a pound a month. 

An infant at the sixth month should have twice its initial weight ; 
and at the end of the twelfth month a normal infant should weigh 
20 to 21 pounds, or 9000 to 9800 grammes (Fig. 2). 

Within physiological limits the weight given above will vary, 



22 



THE NORMAL INFANT AND CHILD. 



and there are normal infants who may weigh a pound less or a 
pound more than the figures given. This is accounted for by vari- 















Fig 


1. 














DAY3 




1 


2 


3 


4 


5 


6 


7 


8 


9 


10 


11 


lbs. 


1- 
I 

E 

3,100 
75 
50 
25 

3,000 
75 
50 
25 

2,900 
75 
50 
25 










































































r 


























/ 


























/ 




6.8 






















/ 
























' 
























/ 


























/ 


























/ 


























/ 


























/ 


























/ 


























/ 


















































1 




















































I 


























j 




















































J 


























j 


























I 


















































/ 










6.6 


\ 














/ 










\ 














/ 












\ 














/ 












\ 














/ 












\ 














/ 












1 














/ 


























r 














\ 










1 
















\ 


























\ 










f 
















\ 










/ 
















\ 










/ 
















1 










/ 


























/ 


























/ 










































1 








/ 


























/ 


























/ 


























/ 














6.4 












/ 
























/ 


























/ 














































/ 
















6.3 






1 




/ 
























/ 


























/ 


























/ 






















\ 




/ 






















1 




























/ 
























\ 


/ 
























\ 


/ 
























\ 


/ 


















6.1 






V 





























































































































Normal curve of weight during the first ten days of life. (Budin.) 

ation in the size of the skeleton, so that we cannot fix an abso- 
lute weight of 20 or 21 pounds as the normal weight of an infant 
at the end of twelve months, but only as an average weight. 



THE BODY- WEIGHT. 



23 



Increase of weight differs also in artificially fed (bottle-fed), as 
compared to breast-fed, infants. The quantity of milk necessary to 
maintain nutrition is greater than in the case of the breast-fed infant. 
There is always the danger of overfeeding an infant on the bottle. 
The increase in weight is not so regular as in the breast-fed infant, 
as is shown in the following table : 

Fig. 2. 





MONTHS 2 3 4 5 


6 7 8 « lO n 12 




DAYS 1 1 


W lEKSl 1 1 


















. . ^ - i - - '2 






- ,'' IT 4 


















: :::: ::: ::::;! : :: ::. i^ 






It^-' - -5 


















: :::::: ^ I- :: : : i^ 






€. » 






:_ :__:::_;«:::_:_:._:_:_:_:: _-:.--^ 






2=. g 






— z _: : - I IS 






i^ ° 


















Z '^ 
























/ '^ 












A 












- - --- - - - : : : : : : : X ; : : : 2 
























~ ■ " - '2 








o 


i.:- ::-::::_: ::: ::::_ ::__::7::;_:;_ 










T 




- - - - - - - ^^ ^ 


rf- 




"I : ::: :::_ :__ : : ::: : :::; » 








'5 - - -J 


























■-TTi "" i: — It 




- -- .- 2 


--. .-- --- -_ - .- --|--- - ,2 






X » 
























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. . 7 






I 












3. :';■ ----- 


"I " " ~~r .s 




/ 


-11- - - -^ ,a 




- ■ \W- / 


:::::::: ::: :: ::: :±t:- - « 




^.!::::" -■ ] = = = = = = = = £ = = === = 


= = =i== = = = ==" = = = = = ======£=.= J- 
















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8 . ^. , 


- - . - ---... _ - - - g C 




7 1., . - - - 


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: : : : _::::: -' -- --^ 2 


^ 




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4---,-. .-. I": : : 


— - - 4 





2 \\A 


C 3 




7^ :::::.::::::::: 


_-j_ _^ ^ __ 












- - r* w 






- " i 7 










II 








I : I - 1 1 ~ io ° 









Author's chart showing the average weight of breast-fed infants from birth to the end of the 

fiftv-second week. 



r Weeks 1—2 2—4 4—8 8—12 12—16 16—20 20—24 
I Increase 4 21 21 22 22 25 22 

! Weeks 24—28 28—32 32—36 36—40 40—52 

Camerer \ j^^^^^^^^ -^3 ^g ^g 9 12 

I Months 123456789 10 

L Weight 3810 4430 5090 5800 6550 7180 7650 8140 8600 8880 

T^ i-i j Months 123 4 5 6 7 8 9 

J^opii^ I Weight 3735 5068 5285 5518 7688 7223 8680 9021 



24 THE NORMAL INFANT AND CHILD. 

In the tables on pages 23 and 24 are shown in grammes not only 
the irregularity in the daily increase, but also the irregularity in the 
total weight. My own cases were examined with a view to deter- 
mining what an artificially fed baby weighs if it is thriving. The 
figures correspond closely to those given by Camerer. 

The following table shows in grammes the daily increase of weight 
of the breast-fed and the bottle-fed infant : 

,,_^.,„ AMfeld Camerer Koplik 

Monins. (breast). (bottle). (bottle). 

1 31 21 32.0 

2 26 22 17.4 

3 24 22 23.6 

4 21 25 18.0 

5 . . 18 22 14.2 

6 15 13 11.8 

7 15 16 15.6 

8 16 16 15.1 

9 9 9 — 

Length of Body. — At birth an infant measures from 49 to 50 
cm. (19f-19| in.) in length; boys on the average having a greater 
length than girls. During the first year the increase in length is 20 
cm. (7| in.). Thus, at the end of the fifteenth year the length of 
the body has increased 100 cm. (39J in.). 

Head. — Herz, in a number of measurements of the head of the 
newborn infant, found that the 

Average circumference of the head was 39.2 cm. (15.6 in.). 

Sagittal diameter 11.1 cm. ( 4.4 in.). 

Large transverse diameter 9.0 cm. ( 3.6 in.). 

The latest measurements of the head of infants, beginning at birth 
and extending to the twenty-fourth month, were made by Hrdlicka 
and Pisek, under the guidance of Dr. Chapin. These measure- 
ments are applicable to American -born infants, and are probably 
the most reliable we have. (See table below.) 

The newborn infant has a formation of the caput succedaneum 
and in some cases of a cephalohcematoma, which will be treated of 
in a separate section. The fontanelles, however, are of import- 
ance and may be spoken of in this connection. They are caused 
by the apposition of the cranial bones — the parietal, frontal, and 
occipital — which at first are circular, and at the points of non- 
contact form triangular spaces, the fontanelles. These spaces are 
at first closed by membrane only. At birth, or soon thereafter, 
the posterior fontanelle closes ; the anterior fontanelle, however, 
remains open. The time of closure of the anterior fontanelle is of the 
utmost clinical importance. Kassowitz and Hochsinger contend that 
the anterior fontanelle grows smaller from birth to the end of the 
first year, and closes at from the twelfth to the fourteenth month. 
Elsasser and Rhodes, however, contend that, while the lateral and 
posterior fontanelles close during the first months of infancy, the 



BESPIRA TOR Y FUNCTIONS. 



25 



anterior fontanelle increases in its longitudinal and transverse diam- 
eters with the growth of the cranium up to the twelfth month. 
Most writers, however, are inclined to accept the view of Kasso- 
witz and Hochsinger. If the closure of the anterior fontanelle is 
delayed until the fifteenth month, we may look upon it as a sign of 
rachitis. 

Oircumferenee ^ of the Head. 



Age. 


Male. 


Female. 


1st day to end of 1st month . . 


■ ■ t 


35.1-38.3 cm. 
13.8-15.1 in. 


33.4-37.1 cm. 
13.1-14.6 in. 


5th to 6th month 


■■{ 


40.5-43.9 cm. 
16.0-17.3 in. 


41.7-44.6 cm. 
16.4-17.6 in. 


11th to 12th month 


/ 


44.7-45.3 cm. 
17.6-17.8 in. 


43.7-46.3 cm. 




I 


17.2-18.2 m. 


22d to 24th month 


■{ 


47.6-49.0 cm. 
18.7-19.3 in. 


45.6 cm. 
18.0 in. 



Respiratory Functions. 

Shape of the Chest. — The ribs of some infants are quite 
apparent to the eye, while those of others are concealed by a pan- 
niculus of fat. The normal chest in the child has not the shape it 
assumes later in life — that of a truncated cone. The lateral por- 
tions are quite straight and parallel. The chest is not flattened 
anteroposteriorly to the same extent as in the adult. In the new- 
born infant the transverse diameter of the thorax is twice that of 
the anteroposterior diameter ; whereas in the adult it is three times 
its length. In infants the superior border of the manubrium sterni 
is on a level with the midsection of the first dorsal vertebra ; in the 
adult it is lower by a body and a half of a vertebra. The tendon 
of the diaphragm is horizontal in the newborn infant, and will be 
found to be on a level with the disk between the eighth and ninth 
dorsal vertebrse. A rachitic chest may be pointed at the sternum, 
forming what is called a chicken-breast. Some rachitic chests show 
a marked flaring of the lower ribs, with a lateral incurvation above 
this flaring ; or they are flattened at the sides and deeper at the 
sternum. The sternum may be the top of a truncated cone, a 
variation from the normal state. Infants and children who have 
had severe attacks of bronchitis and who have some emphysema of 
the lungs show a marked fulness at the upper part of the chest, 
underneath the clavicles. 

Chest Circumference. — The followina: measurements of chest 



^ The circumference is taken just above the glabella in front and the external 
occipital protuberance behind. 



26 



THE NORMAL INFANT AND CHILD. 



circumference are important as showing the development of American- 
born infants from birth to the twenty-fourth month, and were made 
by Hrdlicka and Pisek, under the guidance of Dr. Chapin : 



Chest CirGumference. 



Age. 


Male. 


Female. 


Ist day to end of 1st month < 

5th to 6th month | 

11th to 12th month \ 


32.0-36.7 cm. 
12.6-14.4 in. 

39.9-43.3 cm. 
15.7-17.0 in. 

43.4-45.1 cm. 
17.1-17.8 in. 

42.1-47.7 cm. 
16.5-18.8 in. 

50.7-50.8 cm. 
19.9-20.0 in. 


30.0-35.9 cm. 
11.8-14.1 in. 

38.6-43.2 cm. 
15.2-17.0 in. 

42.8-48.3 cm. 


13th to 14th month | 

23d to 24th month . \ 


16.9-19.0 in. 

45.1-49.4 cm. 
17.8-19.0 in. 

47.1 cm. 




18.5 in. 



The normal number of respirations in infants and children are 
as follows : 

Immediately after birth 44 per minute. 

From the 1st to the 2d month 24-36 " 

2d " 5th " 20-32 

6th " 10th year 20-28 



The character of the respiratory movements in infants and 
children is quite shallow and irregular, especially in sleep, as com- 
pared to the adult. Respiration is of the diaphragmatic type up to 
the tenth year in the female child, and the eleventh year in the 
male, when it takes on the regular type of respiration seen in the 
adult. 

Chemism of Respiration. — Infants nourished upon the mother's 
breast excrete less CO^ than adults (Rubner, Heubner, Bendix). 
Thus, a baby weighing 5 kilos (11 pounds) exhales 13.5 COg per 
square metre of surface ; whereas the adult exhales per square metre 
15.3 to 16.5 CO2 (Rubner). On the other hand, the breast-fed 
child excretes a greater amount of water by way of the skin and 
lungs than the adult, on account of increased respiratory action, 
general activity of the infant, and its warmer apparel. 

The bottle-fed baby excretes a greater amount of CO2 and water 
by the skin and lungs than the breast-fed baby. This is explained 
by the fact that the bottle-fed infant consumes in its food a greater 
amount of nitrogen than the breast-fed infant. 



CIRCULATION AND PULSE. 



27 



Table of the Average Height, Weight, Head Circumference, and Chest 
3feasurements of American Boys and Girls. 

(Collated from thousands of children in various States by Bowditch, Burk, MacDonald, and 

Hastings.) 



Years 
of age. 


Sex. 


Height. 


Weight. 


Head 
circum. 


Depth 
of chest. 


Breadth 
of chest. 


Chest ex- 
pansion. 






In. 


Cm. 


Lbs. 


Kilos. 


In. 


Cm. 


In. 


Cm. 


In. 


Cm. 


In. 


Cm. 


5y,. . . 


f Boys. 
1 Girls. 


41.7 


105.9 


41.6 


18.9 


20.1 


51.2 


4.9 


12.3 


7.1 


18.1 


1.3 


3.4 


41.3 


104 9 


40.7 


18.5 


19.7 


50.2 


4.8 


12.3 


7.0 


17.7 


1.4 


8.5 


61^. . . 


/Boys, 
t Girls. 


43.9 


111.9 


45.2 


20.5 


20.2 


51.5 


5.0 


12.8 


7.2 


18.4 


1.6 


4.2 


43.3 


109.0 


43.4 


19.5 


19.8 


50.3 


4.9 


12.3 


7.0 


17.7 


1.5 


3.8 


7^. . . 


/Boys. 

t Girls. 


46.0 


116.8 


49.5 


22.5 


20.4 


51.9 


5.1 


12.9 


7.4 


18.9 


1.8 


4.5 


45.7 


116.0 


47.7 


21.6 


20.0 


50.9 


4.9 


12.5 


7.2 


18.4 


1.8 


4.5 


sy^. . . 


' Boys. 


48.8 


123.9 


54.5 


24.4 


20.5 


52.2 


5.1 


12.8 


7.6 


19.4 


2.3 


5.9 


1 Girls. 


47.7 


121.1 


52.5 


23.8 


20.2 


51.2 


4.9 


12.5 


7.4 


18.9 


2.0 


5.0 


9>^. . . 


/Boys. 


50.0 


127.0 


59.6 


27.0 


20.6 


52.4 


5.2 


13.2 


7.8 


19.7 


2.5 


6.5 


JGirls. 


49.7 


126.2 


57.4 


26.0 


20.4 


51.9 


5.1 


13.1 


7.0 


19.3 


2.2 


5.6 


loy^. . . 


f Boys. 


51.9 


131.8 


65.4 


29.5 


20.6 


52.6 


5.2 


13.2 


8.0 


20.2 


2.7 


7.0 


\ Girls. 


51.7 


131.3 


62.9 


28.5 


20.5 


52.0 


5.1 


13.0 


7.8 


19.8 


2.4 


6.0 


11^. . . 


/Boys. 


53.6 


136.1 


70.7 


32.2 


20.8 


52.9 


5.4 


13.8 


8.2 


20.9 


2.9 


7.3 


iGirls. 


53.8 


136.6 


69.5 


31.5 


20.7 


52.5 


5.2 


13.1 


8.0 


20.3 


2.6 


6.6 


12^. . . 


/Boys. 


55.4 


140.7 


76.9 


34.9 


21.0 


58.3 


5.6 


14.1 


8.5 


21.5 


3.0 


7.8 


1 Girls. 


56.1 


142.5 


78.7 


35.7 


20.9 


53.0 


5.4 


13.8 


8.4 


21.0 


2.4 


6.2 


13J^. . . 


J Boys. 
1 Girls. 


57.5 


146.0 


84.8 


38.5 


21.1 


53.5 


5.6 


14.3 


8.7 


22.1 


3.2 


8.2 


58.5 


148.6 


88.7 


40.3 


21.0 


53.5 


5.5 


14.1 


8.7 


22.1 


2.6 


6.6 


14^. . . 


/Boys. 


60.0 


152.3 


95.2 


48.2 


21.3 


54.1 


5.9 


15.0 


8.9 


22.7 


3.3 


8.4 


JGirls. 


60.4 


153.4 


98.3 


44.6 


21.3 


54.1 


5.7 


14.5 


9.0 


22.9 


2.7 


6.8 


15^. . . 


/Boys. 


62.9 


159.7 


107.4 


48.8 


21.4 


54.5 


6.3 


16.0 


9.3 


23.6 


3.3 


8.4 


1 Girls. 


61.6 


156.4 


106.7 


48.5 


21.5 


54.6 


6.0 


15,3 


9.5 


23.8 


2.6 


6.5 



Table of Weight, Length, Head Cii'cumference, and Girth of Chest 
from Birth to the End of the Fourth Year. 



Age. 



Birth . . . 

6 months 

12 months 

2 years . . 

3 years . . 

4 years . . 



Sex. 


Length. 


Weight. 


Head 
circum. 


Chest 
girth. 




In. 


Cm. 


Lbs. 


Kilos. 


In. 


Cm. 


In. 


Cm. 


/Boys. 
JGirls. 


19.7 


50.0 


7.4 


3.45 


18.8 


35.1 


12.6 


32.0 


19.8 


49.0 


7.1 




18.1 


88.4 


11.8 


30.0 


(Boys. 
JGirls. 


25.4 


64.8 


16.0 


7.2 


16.0 


40.5 


15.7 


39.9 


25.0 


63.6 


15.5 


7.0 


16.4 


41.7 


15.2 


38.6 


(Boys. 


29.5 


73.8 


21.5 


9.8 


17.8 


45.3 


17.8 


45.1 


JGirls. 


28.7 


78.2 


21.0 


9.5 


18.2 


46.3 


19.0 


48.3 


/Boys. 


83.8 


84.5 


80.3 


13.8 


19.3 


49.0 


20.0 


50.8 


JGirls. 


82.9 


82.8 


29.2 


13.3 


18.0 


45.6 


18.0 


48.0 


f Boys. 
JGirls. 


87.0 


92.6 


34.9 


15.9 


19.8 


49.0 


20.1 


51.1 


36.3 


90.7 


33.1 


15.0 


19.0 


48.4 


19.8 


50.5 


/Boys. 


39.3 


98.2 


87.9 


17.2 


19.7 


50.3 


20.7 


52.8 


JGirls. 


38.8 


97.0 


36.8 


16.5 


19.5 


49.6 


20.5 


52.2 



Circulation and Pulse. 

Circulation. — According to the investigations of Vierordt, the cir- 
culation in the newborn infant is completed in 12 seconds; in the child 
of three years, and up to the seventh year, in 15 seconds ; in the child 
of fourteen years, in 18 seconds; and in the adult, in 22 seconds. 

Pulse. — Its Rapidity. — The following is the rapidity of the pulse 
at the various ages of infancy and childhood given by Bednar : 

Beats per minute. 

Foetus 108 to 160 

First two minutes of life 72 to 94 

Fourth minute of life 140 to 208 

Eighth day to second month 96 to 130 

Second month to twenty-first month 96 to 120 

Second to fifth year 92 to 108 

Fifth to eighth year 84 to 100 

Eighth to twelfth year 76 to 96 



28 THE NORMAL INFANT AND CHILD. 

The pulse-respiration ratio in infants is as 3 or 5 to 1. If we 
consider that the respiration in these little subjects is 30 to 32 a 
minute, the ratio of the respiration to pulse will be as 1 to 4 in 
infancy ; 1 to 5 or 6 in the second year. Turning, crying, cough- 
ing, or any excitement will increase the pulse-beat 15 to 30 a 
minute. During sleep the pulse varies from 15 to 20 beats per 
minute. After the third month the pulse is more rapid in girls 
than in boys. 

Rhythm of the Pulse. — The rhythm of the pulse has been 
the subject of much investigation by various observers, and the 
author can lay stress on the following peculiarities of the normal 
pulse : 

(a) In infants and children the pulse is normally arrhythmic or 
irregular, both in regard to time intervals and in relation to what is 
known as the respiratory curve in sphygmographic tracing. 

(6) Dicrotism is a normal characteristic of the pulse in infancy 
and childhood. The irregularity of the pulse in some infants and 
children is not very marked ; in others this irregularity becomes 
more apparent under the influence of undue excitement. Dicro- 
tism, although very evident and due to the great arterial elasticity 
in children (Landois), is never as marked as in cliildren who are the 
subjects of cardiac disease, pertussis (heart strain), or acute infection 
(typhoid fever). On the whole, it may be said in regard to the 
pulse, that it is more subject to variability as a result of slight 
influences than that of the adult. 



Body-temperature. 

The temperature of the newborn infant will vary from 36.9° to 
38.4° C. (98.4°-101.1° F.). The latter is exceptional. According 
to the studies of Lachs, the average temperature of the newborn 
infant varies from 37.5° to 37.9° C. (99.5°-100.2° F.). After 
the first bath the body-temperature falls between 1.7° and 2.5° F. 
Two hours after the first bath the temperature begins to rise, and 
reaches its original height within twenty-four hours, or sometimes 
later. In premature or weakly infants the temperature does not 
reach its original height for fully three days, and in some instances 
it may never reach the original height. 

The body-temperature of infants shows slight fluctuations during 
the day which are quite normal. The maximum temperature in 
most cases is reached at midday or during the afternoon ; the 
minimum, during the morning and evening. The daily fluctuations 
vary from 0.1° to 0.3° F. The daily fluctuations of temperature are 
more regular and uniform in the breast-fed infant as compared to 
the bottle-fed infant (Marfan). During sleep the temperature may 
sink from 0.3° to 0.5° F. (Alix and Vierordt). In a general way we 



URINE. 29 

may say that in infants and children any rectal temperature ranging 
from 99.3° to 100° F. is normal. 

Crying, excitement, or exercise will raise the temperature in 
infants and children from one-half to several degrees. I have 
seen an instance of a boy, seven years of age, with a normal tem- 
perature, observed throughout the course of two or more years, 
of 100.5° F. at midday, which would rise 1° F. in the rectum 
after five minutes' exercise. This boy was otherwise in perfect 
health. 

The following table of body-temperatures (rectal) is the result 
of the investigations of Lachs, Vierordt, and Alix : 

Newborn infant 37.5° to 37.9° C. (99.5°-100.2° R). 

5-16 months . . 37.4° to 37.9° C. (99.3°-100.2° R). 

20 raonths-4 years 37.5° to 37.9° C. (99.5°-l 00.2° R). 

5-9 years 37.6° to 37.8° C. (99.6°-100.1° R). 

Heat Calories. — Children, according to Vierordt, produce more 
heat calories, per kilo of body-weight, in the twenty-four hours than 
do adults ; thus, in children there are 130,681 calories per kilo 
produced as compared to the adult, where we find 39,640 calories. 
If, on the other hand, we accept the investigations of Rubuer, in 
which the calories are calculated per square metre of body-surface, 
the infant does not use up any more calories than the adult : 1050 
to 1200 as compared with 1300. The infant, for its size, therefore 
gives off more heat from the body-surface, and is therefore more 
sensitive to loss of heat than the adult. 



Urine. 

Physical Characteristics. — The urine up to the eighth day of 
life is dark in color, contains epithelial cells, leucocytes, and uric 
acid crystals. After the eighth day the urine is a limpid, clear, 
colorless fluid. The urine of artificially fed infants is somewhat 
darker than that of breast-fed infants, and especially is this so in 
any disturbance of the functions of the gut. If there is jaundice 
the urine may contain biliary pigment. 

The urine has a resinous odor, as in the adult. The specific 
gravity during the first three days of life ranges from 1010 to 1012; 
after the tenth day, when the infant has partaken of liquid food, the 
specific gravity falls to 1003 or 1004. It frequently happens that 
the newborn infant does not pass urine on the first or even the 
second day of life. This is sometimes misinterpreted as due to 
some obstruction, either in the ureters or external genitals. From 
the second to the tenth day the infant voids urine two to three 
times in the course of the twenty-four hours. Ruge and Robin 
have found that at the third month the infant voids urine ten 
to eleven times in the twenty-four hours, passing 400 to 500 



30 THE NORMAL INFANT AND CHILD. 

grammes in that time ; at the fifth month^ 400 to 500 grammes 
daily ; from the second to the third year, 500 to 600 grammes ; 
from the third to the fifth year, 750 grammes ; and from the sev- 
enth to the tenth year, 1200 grammes daily (Parrot and Robin). 

The following table gives not only the quantity of urine passed 
during early infancy and childhood, but shows the difference in 
amounts passed by the breast-fed and the artificially fed infant. 
It will be seen that, owing to the larger gross quantity of fluids 
taken into the body by the artificially fed infant, the amount of 
urine passed is greater than that of the breast-fed infant. The 
amount of urine is also dependent on the composition of the food. 
Camerer has shown that, as a rule, every 100 grammes of food will 
yield 68 grammes of urine. 

Daily Quantity of Urine (Reusing). 

Breast. Bottle. Specific gravity. 

1st day 8.4 35.8 1010 

2d " 26.8 71.0 1010 

3d " 40.9 135.8 1010 

4th " 60.8 187.0 1010 

5th " 119.1 283.0 1005 

7th " 157.0 325.0 1005 

8th " . 208.0 406.0 1005 

30th-150th day 350 \tj^^^,, imo 

150th-325th" 425/^^^^^'^ ^"^"^ 

2d year 675 1012 

3d-5th " 600-1200 1010-1012 

6th " . 1295 1012 

10th '' 1866 1010 

The infant passes five or six times as much urine per kilo of 
body- weight as the adult ; the child, three or four times as much. 

Urea. — Urea is excreted in greater quantities by the artificially 
fed infant and the infant fed by a wet-nurse than by infants fed at 
the mother's breast. Reusing found that in the infant at the 
mother's breast the amount of urea increases from the first to the 
third day, when it is highest. The reason of the diminished excre- 
tion of urea at this period lies in the fact that there is an insuffi- 
ciency of food during the first days of life. The tissues of the body 
are burnt up in the processes of metabolism, hence there is a dimi- 
nution of weight. Inasmuch as the body is rich in fat, this is burnt 
first and nitrogen is saved. As a result, the nitrogen excretion in 
the first days is less than it is later, when sufficient food makes up 
for the loss of body-weight. Added to this fact of insufficiency of 
food, there is a paucity of fluid nourishment during the first days, 
causing a retention in the body of the end-products of metabolic 
processes. After the first few days in the newborn infant, as in all 
cases of starvation, there is an increase of nitrogen excreted until 
by means of increased food metabolism attains its equilibrium and 
urea is excreted in normal quantities. 



URINE. 31 

Daily Amount of Urea. 

Breast-fed. Bottle-fed, 

1st day 0.06 0.33 

2d " 0.26 0.40 

3d '' 0.52 0.67 

4th " 0.50 0.55 

5th " 0.78 0.65 

6th '' 0.79 0.61 

7th " 0.81 0.88 

30th-]50th dav 0.94 

2d year 9.87 

3d-5th " 13.9 

10th *' 20.4 

Albumin. — Albumin is found in the urine, according to Flens- 
burg, in 40 per cent, of newborn infants. He attributes its pres- 
ence to the existence of uric acid infarction in the kidney at this 
time. Other authors contend that albumin is not present normally 
in the urine of infants, but if the mother has during delivery suf- 
fered from eclampsia, the urine of the newborn infant may contain 
albumin and casts. Czerny regards the whole question of albumi- 
nuria in the newborn as sub judici, inasmuch as in the cases inves- 
tigated, including those of Flensburg, no mention has been made of 
or consideration given to disturbances of the functions of the gut or 
other abnormal conditions which might have been present at that 
time, and he is inclined to believe that if such consideration were 
given, it would be found that the appearance of albumin in the 
urine of infants is in some way connected with the disturbances of 
the functions of the gut. 

Indican. — Indican is absent from the urine of the healthy 
breast-fed infant ; whereas it is found in traces in the urine of arti- 
ficially fed infants, even in the absence of any disease. It is espe- 
cially constant in the urine of infants suffering with gastro-enteritis, 
and may be present in the urine of infants suffering from a number 
of maladies, especially forms of suppuration. It is present in the 
urine of infants suffering from tuberculosis, but is not pathogno- 
monic of that affection (Zamfiresco). 

Acetone. — Acetone is present in small quantities in the normal 
urine of infants and children, and is found also increased in quan- 
tity in the case of fevers, such as the exanthemata, or pneumonia. 
The amount of acetone increases in proportion to the height of the 
fever. It disappears or diminishes to the normal quantity with the 
disappearance of the fever. It is enormously increased in the urine 
of children during a seizure of eclampsia. It is not, however, the 
cause of the eclamptic seizure, as has been supposed. The cause of 
acetonuria is not clear. It is due neither to the hindrance of respi- 
ration nor to fermentation in the stomach or intestine ; but is prob- 
ably due to splitting up of the nitrogenous substances of the body, 



32 MENTAL AND PHYSICAL DEVELOPMENT OF THE INFANT. 

inasmuch as it is increased by a nitrogenous diet, and may be caused 
to disappear by an exclusively carbohydrate diet (Hammarsten). 

Diacetic Acid. — Diacetic acid is not a physiological constituent 
of the urine, but occurs chiefly under the same abnormal conditions as 
acetone. There are cases in which acetone but no diacetic acid appears 
in the urine. Diacetic acid is often found in the urine of children 
suifering from some fever, such as one of the exanthemata. Inas- 
much as diacetic acid is readily decomposed into acetone, it is prob- 
ably an intermediate product in the oxidation of /?-oxybutyric acid 
in the organism. Acetone, diacetic acid, and /9-oxybutyric acid stand 
in close relationship to one another. 

Urobilin. — Urobilin is absent from the urine of the breast-fed 
infant, but is found in traces in the urine of artificially fed infants 
(Giarre and Czerny). 

Dextrose. — Dextrose is found in traces in the urine of infants, 
as it is in that of adults. Dextrose is not found in the urine of 
healthy infants, and only appears in the urine of infants suifering 
from gastro-intestinal disturbances who at the same time may be 
taking food rich in glucose or maltose (Koplik). 

Oasts. — Hyaline and epithelial casts may be found in small 
numbers in the urine of the newborn infant. 

Uric Acid Infarction. — Virchow has described these infarctions 
in the kidneys of newborn infants. They consist of red or brownish- 
red structures, which on section of the kidney are seen to be depos- 
ited in the pyramids of the organ, stretching from the papilla of the 
pyramid halfway, rarely extending to the border of the medullary 
portion of the organ. They exist in the kidneys, as stated, of the 
newborn infant, reach the height of formation on the second, and 
are not found after the sixth day. In the newborn infant there is a 
hyperleucocytosis, which is more pronounced in those cases in which 
the cord has been tied late. The quantity of uric acid in the urine 
of the newborn is much greater than it is later. In the tubules of 
the kidney there is an accumulation, especially in the tubuli contorti, 
of a hyaline substance which is the result of cell production. In 
this hyaline substance are deposited crystals of uric acid, and it is 
in this way that the infarctions are formed. The increased uric acid 
production is in some way connected with the hyperleucocytosis 
above mentioned ; the leucocytes are disintegrated and uric acid 
thus produced. It has not been explained, however, why there is 
an increased elimination of uric acid with resulting infarctions at this 
period and not later in infancy. 

VI. MENTAL AND PHYSICAL DEVELOPMENT OF THE 

INFANT. 

It is not our purpose to enter into every detail of the development 
of the senses of the infant, for this would scarcely be called for in this 



MENTAL AND PHYSICAL DEVELOPMENT OF THE INFANT 33 

section. On the other hand, there are certain important facts which 
are of great utility to the physician in his daily clinical work. 

Sight. — On the second day the eyes are sensitive to light. On 
the twenty-first the eye will follow a light ; and at the beginning of 
the second month the infant will notice bright colors. At the third 
month the infant will recognize a familiar face. At the sixth month 
the infant will definitely recognize its parents apart from strangers. 

Hearing. — A newborn infant is deaf. This is due, it is sup- 
posed, to the blocking up of the Eustachian tubes with mucus. On 
the fourth day there are evidences of hearing, which develop from 
this time to the fifth week, when loud talking or noises in the room 
disturb the infant. At the sixth month the infant will recognize 
noises as to their varying tone. 

Taste. — The sense of taste is not fully developed until the sixth 
month. From the fourth day, however, an infant will show a 
preference for sweetened, as compared to unsweetened, dilutions of 
milk. 

Feelings of Pleasure. — An infant will show decided pleasure 
at the sight of playthings at the fifth month, but can hardly be said 
to take an intelligent interest in any object before this time. 

Power to Hold the Head Upright. — The newborn infant can- 
not hold its head upright, and when held in arms the head will 
sway from side to side. The power to hold the head upright is not 
fully developed until the fourth or fifth month. This is important 
clinically in connection with certain diseases, such as amaurotic 
idiocy, the development of which is attended with a loss of power 
to hold the head upright. 

Sitting. — The infant will make the first attempt to sit up at the 
fourteenth week ; but is unable to sit upright without assistance 
until the forty-second week. 

Standing. — The first attempt to stand without support is made 
by the infant at the tenth month. In the eleventh month the 
infant may not only stand, but even stamp its foot. Walking and 
standing are delayed by rachitis. In such cases the infant may 
even cry if placed on its feet, on account of the pain such children 
experience in the bones. 

Crawling and Walking. — The infant will crawl on all fours in 
the fifth month. Attempts to walk begin at various periods, some 
infants being more precocious in this respect than others. The ear- 
liest attempts to walk are made in the tenth month. At the four- 
teenth month an infant will walk if held by the hand. It will stand 
alongside a chair in the fifteenth month, and in the seventeenth 
month a child will walk unsupported. 

Laughing. — An infant two months of age may be caused to 
laugh in a purely reflex fashion by gentle titillation at the corners 
of the mouth or on the chin. An intelligent laugh, however, is not 
observed until the sixth month. 

3 



34 METHODS OF EXAMINATION. 

Kissing. — Kissing involves the act and the understanding 
thereof, and these are seen combined only quite early in childhood — 
the twenty-third month. 

Memory. — True memory is observed first in the tenth month, 
when the infant will recognize the face of the parent after a short 
absence. In the twenty-first month the child will recognize its 
parents after a protracted absence. 

Speech. — On the forty- third day the infant may articulate unin- 
telligible sounds. At the fourteenth month it will be able to say 
mamma and papa ; and at the end of the second year the child 
attempts the formation of simple sentences. In a general way, it 
may be said that the infant will show signs of intelligence, includ- 
ing sight, hearing, and vocal effort, at about the seventh month, and 
will first attempt to walk at the tenth month. There will be, of 
course, a wide variation in different infants in the development of 
the senses ; and yet we will always recognize as pathological the 
vacant stare, a total lack of utterance, an indifference to bright 
objects, and an inability to stand on the mother's knee, or to hold 
the head upright at the seventh month, especially if other abnor- 
malities, such as protruding tongue, are present. 

VII. METHODS OF EXAMINATION. 

Taking" a History. — Beginning with a few leading questions, 
the physician inquires as to the sex and age of his patient, the 
number of children in the family, and the use of instruments, such 
as forceps, in the delivery of the infant. The methods of feeding 
the infant from the outset, are inquired into, and the success attend- 
ing these methods. If the patient is in the period of dentition, the 
order of the eruption of the teeth is ascertained. After elicit- 
ing information in regard to any previous illness, the physician 
proceeds to the details of the existing affection. In the greatest 
majority of cases an illness in infants begins with fever, chill, cyano- 
sis, or vomiting. One of these symptoms may be present to the 
exclusion of the others, or they may all be present, or the illness 
may be ushered in with a convulsion. The condition of the patient 
immediately following the initial symptom constitutes the initial 
stage of the illness. Fever or unconsciousness may follow a chill or 
convulsion, or the patient may after the initial symptom develop an 
eruption, cough, dyspnoea, or pain. The fever may subside in a 
few hours, and the temperature return to normal, with a subsequent 
rise, preceded by a chill, cyanosis, or a second convulsion. Older 
children may complain of pain, as adults do. In the case of an 
infant, pain in the chest or abdomen may be indicated by an increase 
in the number of respirations or a sighing or moaning with each 
effort at respiration. 

The vomiting of the initial stage of the illness may not be 



THE HEAD. 35 

repeated, or it may recur and form a leading feature. The nature 
of the vomited matter is important. It may have an acid reaction 
or odor, or may consist of stomach contents mingled with biliary 
pigment. It may be streaked with blood. In serious continued 
vomiting it may assume a fecal character. Vomiting may occur 
with the ingestion of food or independently of it. 

The condition of the bowels is of importance. The movements 
may be numerous but of normal consistency and odor, or they may 
be diarrhoeal and have abnormal features. The movements may be 
accompanied by tenesmus or prolapse of the gut. The urine of 
sick infants is sometimes not passed for hours. The mother will 
make a note of this fact. The character of the urine is next to be 
ascertained. Its passage may be painful. The urine may stain the 
diaper yellow (jaundice) or red (lithiasis) ; it may contain blood. 
Older children may be required to pass the urine. The quantity is 
more easily estimated in older children than in infants. With t-he 
latter we should be cautious in drawing conclusions as to the daily 
amount. In taking a history as above, it is essential, while eliciting 
the main features of an illness, not to inquire concerning unimpor- 
tant details. The main features of the history should be grasped 
and completed in all their minutise. 

Taking the Status Praesens. — It often happens that the infant 
or child is asleep during the first portion of the visit. Under that 
condition the respirations and pulse, Avith the character of each, can 
be noted. The posture during sleep, the expression of the face and 
its contour, the position and behavior of the extremities during rest, 
are of the greatest import, j^espiration during rest is more instruc- 
tive than in a condition of unrest and wakefulness. The patient 
should be completely undressed for examination. This is done as a 
routine procedure even in cases of apparently mild illness. Any 
eruption on the skin is thus forced upon the attention of the 
physician. 

The Head. 

The examination of the head should begin with observation of 
its size, whether normal or abnormally small or large. The general 
shape of the head and condition of the bones are of importance in 
reference to the presence or absence of rachitis and areas of 
crardotabes. The manner in which the head is held is noted, as 
bearing on the presence of torticollis. In Pott's disease the head 
is held rigidly on the spine, and in older children supported with 
the hands. Some infants, for instance, amaurotic idiots and those 
suffering from birth-paralyses or diphtheritic paralysis, are unable 
to hold the head upright. In forms of meningitis the head is 
retracted or held rigidly. The fontanelles may be normal, tense, 
depressed, or abnormally prominent ; they may be closed prema- 
turely or open beyond the normal period. The presence of tumors 



36 METHODS OF EXAMINATION. 

underneath the scalp should be noted. The condition of the lymph- 
nodes posterior and anterior to the border of the sternomastoid 
muscle is of clinical importance. 

The Face. 

The expression of the face in a condition of rest, and also when 
the infant or child cries, may enlighten us as to the presence or 
absence of paralyses. These may be localized, involving the muscles 
of one organ, such as the eye, or the whole side of the face may be 
affected. When the infant is asleej) the mouth is normally closed 
and the infant breathes through the nose, the tongue being applied 
to the roof of the mouth. In abnormal states the breathing may be 
noisy ; the cry may be peculiar, as described under Retropharyngeal 
Abscess ; the lips may be cyanosed or the seat of rhagades or erup- 
tions, such as herpes ; the symmetry of the face may be lost, as in 
parotiditis or adenitis, in which there is a swelling of one or both 
sides of the face. 

Cardiac disease in advanced stages gives a sad and anxious 
expression to the countenance. 

Facial paralysis, either partial or complete, causes a character- 
istic facial expression. If the infant cries, or the child is made to 
smile, one side of the face remains immobile. Even in rest the 
angle of the mouth may be drawn toward the unaffected side of the 
face, as in tuberculous meningitis. 

In nuclear palsy of the congenital variety described by Moebius 
and Schapringer (pleuroplegia) both sides of the face are immobile, 
and the face has a mask-like expression. There are no folds in the 
face either in the acts of laughing or crying. 

Basedow's disease gives a peculiar expression to the face, caused 
by the prominent eyeballs, which is pathognomonic of this disease. 

Hydrocephalus likewise gives a peculiar facial expression. The 
forehead is protuberant and overhanging. The eyeballs are forced 
downward, and the sclera are seen. The face proper is small as 
compared to that part of the head above the eyes. This is due to 
the large size of the cranium. 

Rachitis at times causes a characteristic expression which is 
likely to be confounded with that due to hydrocephalus. In some 
rachitic infants the eyes are prominent and the sclera can be seen 
slightly. The orbital plates of the frontal bone being thin, the 
weight of the brain depresses the eyeball to a very slight degree. 

Exhausting" diseases, such as diarrhoea, cause prominence of 
the eyes, giving a very characteristic expression — the so-called 
hydrocephaloid of older writers, 

Congenital syphilis in some cases causes a deformity of the nose, 
which is present at birth. The result is a peculiar angular deformitv 
of the normal nasal curve, Looked at sideways, the bony septum 



SIGHT— PHYSICAL EXAMINATION OF THE CHEST, 37 

is depressed ; the cartilaginous septum is still intact. A very acute 
angle between the two results. This is similar to what is seen in 
destructive forms of syphilis later in life. The facial expression is 
characteristic of the disease. 

The angle of the palpebral fissure is altered in conditions 
such as Mongolian idiocy. In this affection it is slightly oblique. 
In paralyses of the ocular muscles the palpebral fissure itself may 
be wider in one eye than in the other. The presence or absence of 
conjunctivitis, keratitis, nystagmus, paralyses of the orbital muscles, 
the condition of the pupils, are all points of importance in deter- 
mining the status prsesens. In diseases of the brain or its coverings 
an ophthalmoscopic examination of the fundus oculi should be made. 

Sight. 

In partial or total blindness, not only do the patients not notice 
objects placed in front of them, but there is in addition a vacant 
expression or stare. If the blindness is total, the finger will be 
suffered to approach the eye so as to touch the cornea. 

Some infants have a tendency to hold the head to one side. This 
may be due to defective vision or to weakness or spasm of the mus- 
cles of the neck. In cases of defective vision the head assumes a 
normal position if the eyes are not focussed on any object. As soon, 
however, as an effort is made to accommodate, the head is inclined 
so as to bring the planes of vision of the eyes in accord. 

Photophobia is an aversion to light, and is due to a spasm of 
the ocular sphincter in diseases of the conjunctiva or cornea (con- 
junctivitis, corneal ulcer). 

Nystagmus is a series of involuntary movements of the eyeball, 
due to inefficiency of certain muscles, and is met with in conditions 
of corneal opacity, congenital cataract, albinism, infantile amblyopia, 
spasms, nutation or head-nodding, and in nervous states, such as 
amaurotic idiocy. In weakly rachitic infants nystagmus may be 
exhibited around a horizontal or vertical axis of the eyeball, or it 
may show itself in a rotary oscillation of the globe. It is made 
manifest in infants by causing them to focus some bright object, 
held slightly above and to one side of the head. 

Physical Examination of the Chest. 

Position of the Patient. — An infant should be so held for 
examination that the examiner and the patient may be at ease. 
Being undressed, with the thorax exposed, the infant is first held by 
the attendant with its head looking over her shoulder, in which 
position the arms instinctively clasp her neck (Fig. 3). The patient 
so placed does not see the examiner. The spine should be straight, 
so that in percussing the sound is obtained on both sides under the 
same conditions. To examine the chest anteriorly, the infant is 



38 



METHODS OF EXAMINATION. 



held looking forward, the anterior aspect of the thorax facing the 
examiner. If it is able to sit up, it may be examined in the sitting 
posture, both anteriorly and posteriorly. 

With older children it is best to make an examination with the patient 
sitting upon a table or chair in a position convenient to the examiner. 
If confined to bed, the child must be examined in bed. As a rule, how- 
ever, it is preferable to have the patient taken out of bed into the light. 

Infants and children sometimes try to grasp the instruments of the 
examiner ; gentle suasion will reassure them, force is never necessary. 

Instruments Used. — A stethoscope is absolutely essential to the 
proper examination of the chest of an infant or child. This method 

Fig. 3. 




Method of holding the infant for the examination of the posterior portion of the chest 

and lungs. 



is called mediate examination. We can by its means assure our- 
selves that the whole area of the chest has been carefully investigated. 
Examination by the ear — the immediate method — is uncertain. A 
small area of bronchopneumonia may easily escape detection in infants 
and children of tender age, in whom the axillae and lateral regions 
of the chest should be carefully searched. Direct application of the 
ear to the chest is resented by infants and children, and is not a 



PHYSICAL EXAMINATION OF THE CHEST. 



39 



conveDient procedure for the physician. With the stethoscope he 
can follow the movements of the body of a restless patient. 

The best form of stethoscope to employ is the binaural. The 
instrument devised by the author (Fig. 4) has given him the most 
uniform results. A larger stethoscope, such as that employed for 
examination of the adult chest, does not differentiate the variety of 
sounds as well as this small instrument, and may cause pain to a 
restless infant, inasmuch as the chest-piece must be held too rigidly 
and is likely to press painfully against the chest-wall. 

A steel tape-measure, marked off into inches and centimetres, is 
convenient for detecting inequalities in the size of the sides of the chest. 

Methods of Procedure. — Inspection. — We learn by inspection 
the shape of the chest and the character of the respiratory move- 
ments ; also, the aspect of the cardiac area, the pulsation of the apex 
of the heart, its force and situation. 

Respiration in infants and children up to the age of ten years is 
of the abdominal or diaphragmatic type. The rapidity may be 
counted by noting the movements of the chest or by watching the 
rise and fall of the epigastric region in the recumbent patient. 



Fig. 4. 




Author's form of stethoscope. {Archives Fed., Nov., 1899.) 

The Cardiac Area. — In some infants and children the cardiac 
area may be quite prominent in the absence of any cardiac dis- 
ease. In rachitic infants and children this part of the chest wall 
may conform to the shape of the heart. There remains even in the 
later childhood of rachitic patients a very slight rotundity or fulness 
of the precordial region. If the chest-wall is quite thin, the precor- 
dial region may normally present a wave of pulsation. All these 
signs may be exaggerated in disease of the heart. The apex-beat is 
normally distinguishable. Its force and area may be increased or 
diminished in disease. The apex-beat may be displaced upward 
and outward, or inward toward the median line (conditions of effu- 
sion in pericardium or pleura). 

Palpation. — Palpation, by laying the palmar surface of the hands 
on the chest, is hardly to be attempted with young infants and 
children. In these subjects the chest is so small that this method 
cannot mark out areas of fremitus or absence of the same. To 



40 METHODS OF EXAMINA TION. 

determine its presence, it is more satisfactory to use the internal 
border of the hand, generally the right. The hand is held horizon- 
tally, the internal border pressing firmly against the chest-wall. 
Thus the slightest variations in vibration of the chest-wall can be 
detected. We begin above at the upper border of the chest and 
pass downward, comparing both sides. If the infant or child cries, 
so much the better. If we wish to ascertain the presence of fremitus 
in a baby, we may even cause it to cry. Older children may be 
asked to count or induced to talk. In infants and children fremitus 
is not so marked or useful a sign as in the adult. Normally, it 
diminishes in intensity toward the base of the lung. In some 
children it is detected in the lower part of the thorax only by care- 
ful examination. It is normally well marked along the axillary 
line ; it is most marked along the mid-regions of the chest between 
the scapulae behind. Anything which separates the lung from the 
chest-wall will diminish or extinguish fremitus. Solidification of 
lung tissue will cause better conduction and increase it. 

Percussion. — It is not advantageous to use a pleximeter in 
examining infants and children. The index finger of the left hand 
is laid horizontally on the chest with firm pressure. The skin or 
chest-wall and finger are thus made one medium. Percussion is 
performed by making a hammer of the middle finger of the right 
hand. The force used should come from the wrist ; the forearm 
should be immobile. The stroke is expended upon the middle 
phalanx of the finger on the chest-wall, and should be of a ta])ping 
character, similar to that used in striking the keys of a typewriter ; 
there should not be a pushing motion. The force should not be 
great. A force equal to that necessary in the examination of the 
adult chest would set in vibration all the neighboring chest and 
abdominal organs and cavities, and would not bring out the delicate 
distinctions of sounds necessary to diagnosis. Moreover, to rachitic 
infants and young children a forcible stroke is distinctly painful. 

The Abdomen. 

The abdomen of an infant or child is best examined with the 
patient on a bed or a table covered with a soft blanket. The 
mother's or nurse's knees are not so satisfactory a surface for this 
purpose. The patient should be completely undressed. 

Inspection should include the examination of the skin as to 
color, eruption, presence or absence of oedema, and of the abdomen 
as abnormally rotund or relaxed. In the latter condition we may 
sometimes make out the coils of gut. In diseases which exhaust the 
strength of the patient we distinguish between relaxed and retracted 
abdominal walls. A retracted abdominal wall may be tense and 
incurvated — the so-called boat-shaped abdomen; this is seen in 



THE ABDOMEN. 41 

meningitis. In some rare forms of septic peritonitis also the abdo- 
men may be retracted. The pain of a colicky attack will cause the 
abdominal walls to be tense although not retracted. In intussuscep- 
tion the coils of gut or even the intestinal tumor may be seen on 
the surface. Ascites distends the abdomen, and when marked the 
rotundity is characteristic, and the skin is tense and shining. 

Peritonitis causes tympanitic distention. In perforation of the 
gut in typhoid fever or appendicitis the tympanites is accompanied 
at an early stage, as in the adult, l^y disappearance of the liver dul- 
ness. This sign will aid us more if the liver dulness and flatness 
have been determined accurately in advance of any complications. 

Tumors. — Abdominal tumors give an uneven contour to the 
abdomen. Such tumors are met in diseases of the spleen or kidney, 
enlargements of the liver, congenital renal cysts, ovarian tumors, or 
hydatid cysts. 

Palpation. — We palpate for pain, general or localized, and to 
determine the size and position of the abdominal organs ; for tumor 
whether of or behind the peritoneum, tumors of the liver, kidney, or 
spleen ; enlarged glands behind the peritoneum in the neighborhood 
of the mesentery of the small gut ; polypi in the lumen of the gut ; 
tumors due to apj)endicitis or intussusception. 

In palpating, we follow a certain routine, and palpate in the 
region of the spleen, then over the liver, and finally in the right 
inguinal region (appendicitis). 

Ascites. — The signs are the same as in the adult. 

Tympanites gives the same signs as in the adult. In newly 
born infants there is in rare cases a congenital weakness of the walls 
of the gut. Any disturbance of the intestinal tract results in immense 
distention, which may be distressing to the patient. Non-inflam- 
matory is distinguished from inflammatory distention (peritonitis) 
by the absence of prostration or fever. There is another form of 
distention which precedes death in severe pneumonia or gastro- 
enteritis. Simple tympanitic distention is seen in rachitic children, 
in whom the lower part of the chest is narrowed and the abdomen 
uniformly protuberant; in these children the distention is apparently 
increased by the forward curvature of the spine. Percussion gives 
a uniformly tympanitic note all over the abdominal area, except 
where fseces change the note into a dulness. There is no pain or 
only slight general tenderness. 

Pain. — Children may locate the pain felt in pneumonia, pleurisy, 
or pericarditis in the abdomen. The pain may be referred to the 
upper part of the abdomen. The patient may complain of pain 
radiating to the right inguinal region, and thus in lobar pneumonia 
of the lower portion of the right lung mislead us into a consideration 
of the existence of appendicitis. In diffuse peritonitis the pain is 
general, but in localized disease of the vermiform appendix the 



42 METHODS OF EXAMINATION. 

limitation of pain can be made out even in young subjects. If we 
suspect appendicitis, it is best to examine every part of the abdomen 
for pain before approaching the right inguinal region. 

In connection with pain and its significance, we may emphasize 
the fact that if the abdomen is relaxed (not retracted), showing the 
grooves due to the muscular parts of the abdomen — the bellies of 
the recti muscles, the incurvation of the abdomen just below the 
border of the ribs — we may assume the absence of tympanites. In 
such cases peritonitis is rarely present. Pain, which has no definite 
localization in an abdomen relaxed as above described, may be con- 
sidered as of no serious import. 

The condition of the abdomen in intussusception is described in 
the chapter treating of that subject. 

Polypoid tumors in the lumen of the ascending or descending 
colon may sometimes be distinctly felt in the relaxed abdomen to 
one side of the umbilicus. 

Floating kidney in children has been recently described by 
Comby. The methods of examination in forms of kidney tumor or 
displacements of this organ are described in the chapter devoted 
to those subjects. 

Rectal Exploration. — This is always carried out in the recum- 
bent position. By rectal examination we may establish the presence 
of an abscess in the right inguinal region or of great swelling of 
the appendix in cases in which it is bound down by adhesions below 
the brim of the pelvis or of ischiorectal abscess. Rectal exploration 
is resorted to in all cases in which we are led to suspect the pres- 
ence of an intussusception. In tuberculous peritonitis also, enlarged 
lymph-nodes may be felt through the walls of the rectum. Kidney 
and ovarian tumors can in some cases be felt through the rectum. 

It is not necessary to cause pain in the above procedure. On 
the contrary, rude examination only obscures the case. We should 
seek every opportunity to become familiar with the normal condi- 
tions externally and per rectum, especially in the vicinity of the right 
inguinal region in order to be able to diagnose abnormal states. 

Examination of the Joints. 

Affections of the joints are among the most frequent dis- 
eases of infancy and childhood. The method of examination 
of the joints should be familiar to every physician. If a mother 
states that her baby cries when it is bathed or diapered, we should 
examine the joints. In the newborn infant especially this holds 
true. If there is any limitation of motion, or should the extremi- 
ties be limp, the joints should be inspected. In older children a 
sudden limp or intermittent obscure pain in a joint should receive 
attention at once. 



THE SPINE. 43 

To examine the joints, the patient should be completely un- 
dressed, and placed on a table. The spontaneous movements of 
the limbs are first observed before any manipulation of them is 
attempted. We may thus observe that one limb is favored by the 
infant, limitation of motion may exist, or there may be a marked 
swelling of one joint. The shoulder, elbow, knee, ankle, and other 
joints are systematically examined. This can be done in quite a 
short time if we make it a routine of every physical examination. 
In examining a joint we should not forget that when inflamed, it is 
very painful if not gently handled, and that any rude procedure, 
in addition to causing pain, may injure the joint. 

We first inspect the joint to see whether it is swollen, or has 
its normal form, or shows too plainly the prominences of the 
bones entering into its formation. Palpation will tell whether the 
temperature of the surrounding tissues is raised, whether there is 
fluid in the joint or whether the tissues about it are infiltrated. We 
also examine by mild pressure with the fingers the region of the 
junction of the epiphysis and diaphysis for tenderness. 

Mobility is tested by flexing, extending, rotating, abducting, and 
adducting. During such an examination we also note muscular 
spasm. 

Joint- crepitus is a peculiar crackling, rubbing sensation found 
frequently in the joints of infants and children. It is detected by 
placing the palmar surface of the hand upon the joint and moving 
the extremity which enters into its formation. It has been found 
by the writer in children who complained of no definite joint-symp- 
toms. It may, under these conditions, be present in many joints 
of the same patient. Faint crepitus is found in children who have 
had an attack of rheumatism. 

The most common affections to look for about the joints are 
simple luxations ; syphilitic disease ; osteomyelitis of a septic or 
infectious nature ; scurvy of the joints or epiphyses in the vicinity 
of the joint; rheumatism, simple acute or chronic, and gonorrhoeal; 
tuberculous joints, especially the hip ; paralyses (deltoid) of muscles 
about a joint ; deformities, as in congenital coxa vara. 

The Spine. 

Anatomy. — The spinal column of the newborn infant is practi- 
cally devoid of natural fixed curves. Fehling found that there was 
an almost imperceptible curve backward (kyphosis) in the dorsal 
region and a slight lordosis in the lower lumbar region. The latter 
curve was more marked when the extremities of the infant were 
extended. The fixed curves seen in the cervical dorsal and lumbar 
regions later in life begin to form in the first year. They are fully 
fixed by the seventh year. 



44 



METHODS OF EXAMINATION. 



Method of Examination. — The purpose of examination is prin- 
cipally to discover abnormal curvatures and to test the pliability of 
the vertebral column. In other words, we examine for rigidity due 



Fig. 5. 




Method of testing mobility and pliability of the spine. 

to disease (Pott's). The patient is undressed and made to stand 
erect. The index finger is passed down the vertebral spinous proc- 

FiG. 6. 




Method of testing for psoas spasm. 



esses, and the lines of these processes thus marked out. Any ab- 
normal curve is thus made apparent. Painful areas are detected by 
pressure or tapping along the spinous processes. If deformity is> 



MUSCULAR APPARATUS AND NERVOUS SYSTEM. 45 

present, it is important to decide whether this is permanent and 
combined with muscular spasm (Pott's) or due to rachitis. For 
this purpose the patient is placed on the examining table face down- 
ward. The examiner grasps both lower extremities at the ankles 
(Fig. 5). The palmar surface of the left hand is laid firmly on 
the junction of the cervical and dorsal spine. The extremities are 
now raised and hyperextended with the right hand. If the spine 
is supple and normal, it will curve backward as the pelvis is raised 
toward the vertical. If there is deformity due to Pott's disease,, 
this will persist. Deformity due to rachitis will disappear under 
this manipulation. If the left hand is laid on the lumbar regioo 
and the above hyperextension gently carried out, first flexing the 
legs back at a right angle and then lifting them vertically, a distinct 
spasm of the muscles is felt (psoas spasm) (Fig. 6). Spinal rigidity 
is also made apparent by causing the child to pick up some object 
from the floor. Under conditions of disease the patient will hold the 
spine rigid in picking up the object. The hips and knees are bent, 
but not the spine. To test the rigidity at the outset of a menin- 
gitis, the head is raised as the patient lies recumbent. In meningitis 
the rigidity is such that the whole trunk can be raised by placing 
the palm underneath the occiput and gently raising the head. 

Muscular Apparatus and Nervous System. 

Form. — Atrophy of muscle is seen in any disease which affects 
the trophic centres of muscle in the cord. Such diseases are polio- 
myelitis, and neuritis following traumatism, diphtheria, measles, or 
any infectious disease. Atrophy is seen in joint-affections, especially 
about the hip. In the latter case, not only disuse, but a true reflex 
trophic disturbance is the cause of the atrophy. 

Hypertrophy of muscle is seen in cases of isolated congenital 
hypertrophy of one limb, and also in pseudohypertrophic paralysis. In 
all cases of change of volume of a muscle we first inspect the affected 
limb and compare it with that of the opposite side if the disease is 
unilateral. The diseased limb is measured in its circumference and 
compared with the corresponding healthy limb. 

Patellar Reflex. — We shall take up only that aspect of the 
subject which should concern the practitioner in his examination of 
infants and children. The minutise of electrical muscle and nerve 
reactions may be gleaned from works treating of such matters in 
detail. 

The most common deep reflex is that of the patellar tendon. It 
is obtained by placing the infant in a recumbent position, supporting 
the thigh by placing the left hand beneath it, and raising it above 
the level of the body. When the muscles are relaxed, tap the patellar 
tendon sharply with the middjh finger of the right hand. The 



46 METHODS OF EXAMINATION. 

procedure is similar to that employed in percussion of the chest. Both 
limbs are examined in the same manner. Children who can sit are 
placed on a table with their lower extremities dependent. When 
the attention of the patient is fixed upon some object the tendon is 
tapped sharply. A percussion-hammer is not necessary. 

In diseases of the gray matter and of the posterior columns of 
the cord with trophic disturbance of the nerves (poliomyelitis, neu- 
ritis, Landry's paralysis, diphtheritic paralysis) the patellar reflex is 
diminished or absent. 

In brain tumor and in aflPections of the lateral columns of the 
cord (multiple sclerosis, spastic disease) the reflex is increased. 

The reflex is unimpaired in cerebral palsy, Friedreich's ataxia, 
and in cases of idiocy. 

Babinski's reflex is a plantar phenomenon found in some forms 
of meningitis (tuberculous), and in diseases in which there is irrita- 
tion or involvement of the pyramidal tracts. On irritating the 
plantar surface of the foot with the tip of the index finger there is 
a vigorous hyperextension of the great toe. Morse has shown 
that this reflex cannot be relied upon in children under the sec- 
ond year. I have had abundant opportunity to confirm this 
observation. As a differential diagnostic sign, the Babinski reflex 
is of little value, although I have observed it to be present more 
frequently in the tuberculous forms of meningitis than in the 
pyogenic varieties. 

Kernig's symptom is the flexion of the leg on the thigh when the 
thigh is flexed at right angles to the trunk, and is found in children 
suffering from any form of meningitis, and in diseases such as pneu- 
monia or typhoid fever with cerebral symptoms. The sign has the 
same characteristics as in the adult. In infants under one year the 
tendency to flex the leg on the thigh in the sitting posture is normal. 
In these subjects, therefore, the presence or absence of this sign 
possesses no significance. 

Gait or Walk. — The child is undressed, so that the feet and toes 
are exposed, and is caused to walk to and fro in front of the physi- 
cian. The gait in disease may be ataxic, spastic, paretic, or wab- 
bling. 

Ataxic gait is seen in children suffering from Friedreich's ataxia, 
or from tumor involving the motor centres for the lower extremi- 
ties. The gait is uncertain ; patients walk as if inebriated, with 
the feet wide apart. Incoordination of movement is character- 
istic of all these cases. We must in all cases distinguish between 
simple muscular weakness, as in pseudohypertrophic paralysis, 
and convalescence from acute disease, such as fevers, and a weakness 
combined with a palpable defect in the power of coordinate action. 
In cases of cerebral disease, as a rule, there is lack of coordination 
elsewhere, as in the muscles of the upper extremities. In these 



MUSCULAR APPARATUS AND NERVOUS SYSTEM. 47 

cases the coordination is tested in older children by telling the 
patient to close the eyes, and directing him to touch the tip of the 
nose with the index finger of the right hand several times in succes- 
sion. In cases of ataxia there will be great uncertainty in carrying 
out this manoeuvre. In diphtheric paralysis there may be combined 
with a real weakness, ataxia or incoordinate movement. If we 
remember that in these cases there is a neuritis, with consequent 
atrophy of muscle and loss of reflex, we shall not commit the error 
of overlooking the paralysis in our desire to account for the condi- 
tion present as a simple muscular weakness the result of the illness. 
In these cases there may also be paralyses of the trunk muscles, 
causing inability to assume the upright posture. In ataxia caused 
by cerebral tumor there is in certain cases a crossed hemiplegia 
(pons tumor), with foot-clonus and paralysis of ocular muscles, 
which aid in the diagnosis. 

Cerebellar Titubation. — In cerebellar tumor, which is the variety 
most common in children, there are at the outset, in most cases, 
disturbances of the gait or ataxia. The patients walk in an uncer- 
tain manner, generally staggering to one side. In severe forms of 
this disease the patients will fall to one side if not protected. The 
cases thus far recorded all show early involvement of the optic, 
auditory, and other cranial nerves, abducens paralysis, with symp- 
toms of vertigo. 

Spastic Walk. — This walk is so characteristic as not to be easily 
mistaken for anything else. It is found in all forms of spastic 
paraplegia, congenital or acquired. There is not only actual spasm, 
but also weakness of muscle. There are other phenomena of 
nervous disturbance, such as increased patellar reflex and foot- 
clonus. The patient seems to drag his legs in walking. Each 
extremity is brought rigidly forward, the toes scraping the ground. 
The muscles may or may not be well nourished. Electrical con- 
tractility may or may not be increased. The children may walk 
cross-legged (Gowers). At first there is inability to walk ; later in 
childhood locomotion is possible. In certain forms the spasm of 
the extremities is so great as to keep them in constant extension at 
the knee ; flexion in these cases can only be attained with great 
expenditure of force. 

In infants and children who cannot walk and are the subjects 
of spastic paraplegia the characteristic position of the lower extremi- 
ties may be made apparent by supporting the patient on the feet. 
In all of these cases, as soon as the toes touch the ground the reflex 
produces the characteristic extension of the limbs, with the toes or 
ball of the foot on the ground and the heel raised. 

In very young infants who are the subjects of amaurotic idiocy 
the spastic phenomena are sometimes very marked. In these cases 
there are other symptoms, such as amaurosis and inability to hold 



48 MANAGEMENT AND HYGIENE OF THE NORMAL INFANT. 

the head upright, the presence of the Tay-Kingdon spot in the 
fundus of the eye, to aid in the diagnosis. 

Limping Gait. — Joint-affections cause simply a limping gait ; a 
study of the joint, as described elsewhere, will aid the diagnosis. 

Infantile paralysis, or cerebral palsy, at the outset causes the 
characteristic dragging of the extremity if the paralysis is not com- 
plete. Infants in whom there is a complete loss of power in one or 
both lower extremities give a history as follows : The infant may 
have been able to walk or stand ; the attack suddenly deprives it of 
the power of motion. There is a limp extremity on one or the 
other side, with rapid atrophy of muscle and loss of reflex. In cere- 
bral palsy there is no atrophy and the tendon reflex is present. 

The methods of examining the mouth and special organs will 
be taken up in the chapters devoted to their diseases. 

VIII. MANAGEMENT AND HYGIENE OF THE NORMAL 

INFANT. 

Taking the Infant from the Mother at Birth. — As soon 
as the infant is born and pidsation in the cord has ceased, the 
cord is tied and the physician places the newcomer in the care 
of the nurse. The tying of the umbilical cord should be per- 
formed rapidly, and the nurse, for this purpose, should have at 
hand a piece of sterilized tape or broad binding-silk and scissors 
which have been boiled in water and then carefully wrapped in 
a clean towel. It is not necessary to use silk which has been 
soaked in antiseptic solutions, such as carbolic acid, for the infant 
is peculiarly susceptible to these drugs. I have recently seen an 
infant whose cord was tied with silk saturated with a very strong 
solution of carbolic acid who, within a few hours after birth, showed 
signs of the action of the drug on his economy. The sterilized 
tape and scissors should be in readiness for the physician, as search- 
ing for the tape or scissors causes an inexcusable delay. A warmed 
piece of soft blanket is wrapped about the infant at once. As is 
well known, the infant at birth cries lustily ; nature intends that it 
should be so at this time in order that the lungs may be filled 
with air. 

Tying of the Cord. — The physician should tie the cord, as has 
been stated, with a piece of sterilized tape or broad binding-silk, 
about an inch or an inch and a half from the body, after the pulsa- 
tion of the cord has ceased, unless some feature in connection with 
labor indicates a more rapid procedure. After the initial bath the 
cord is inspected to see that the first ligature is still intact. Ahlfeld 
reties the cord close to the abdominal wall, though this seems to be 
unnecessary. If the ligature is still in place and there is no hem- 



THE CORD AND BATH. 49 

orrhage, the stump of the cord and the surrounding tissues are 
washed with strong alcohol, and a sterilized dry gauze pad with 
inclosed absorbent cotton is folded over the umbilical stump. This 
is held in place with a clean body-binder. The first dressing is not 
removed until the stump of the cord has fallen off and the umbilicus 
has healed, unless there is some indication for its renewal, such as 
the soiling of the dressing by the urine of the infant (Ahlfeld). 

Another method of dressing the cord is to form a pad of absorb- 
ent gauze four or five layers thick, about three inches square, cutting 
a small opening in the centre. The stump of the cord is passed 
through this opening and the gauze folded over the stump. The 
dressing is secured with an ordinary body-binder. This dressing, 
also, is not disturbed unless it is soiled by the urine of the infant. 

Stump of the Cord. — The stump of the umbilical cord dries up 
and falls off from the sixth to the tenth day. It may fall off as 
early as the third or as late as the fourteenth day. In premature 
or weakly infants this process is delayed. Even in healthy infants a 
delay may occur which has no pathological significance. When the 
cord drops off there is a flat, granulating surface left, which cicatrizes, 
and after a time takes on the appearance of the neighboring skin. 
Occasionally, however, the site of the stump takes the form of a 
small pea-like body ; this is pathological and will be discussed else- 
where. Normally there should be no protrusion of the umbilicus, 
even when the baby cries. The drying or mummification of the 
stump of the umbilical cord is a purely physical process, and depends 
more or less on the dryness of the dressing on the stump of the 
cord. When the stump of the cord remains dry, but few bacteria 
are found in the tissues ; if, however, as in very exceptional cases, 
moist gangrene of the stump takes place, staphylococci and strep- 
tococci in large numbers appear in the stump and the immediate 
vicinity. The stump of the cord is thrown off by a sort of reaction- 
ary inflammation at the point of juncture of the amnion sheath of 
the cord and the skin. A few hours after birth the capillary network 
in this vicinity is seen to become congested. The amnion first 
separates, then the arteries, and finally the vein, leaving a granulating 
base at the umbilicus. 

First Bath. — The question has been much debated as to whether 
an infant should be bathed immediately after birth or whether the 
body should be simply anointed with vaseline or olive oil, wiped 
off, and not bathed until the stump of the cord has fallen off. 
Whatever objection there is to bathing premature infants, this 
cannot hold with infants at full term. The bath is cleansing. 
The lochial discharge of the mother if allow^ed to remain in con- 
tact with the skin is apt to decompose, and a source of infection 
is at once presented. 

The most convenient form of bath-tub for the infant, if it can be 



50 MANAGEMENT AND HYGIENE OF THE NORMAL INFANT. 

obtained, is that constructed of rubber sheeting. It obviates placing 
under the infant any blankets, as must be done in a bath-tub made 
of metal. These bath-tubs are constructed so as to have a certain 
height from the floor convenient for the nurse. They hold heat 
better than the metal bath-tub. 

The temperature of the room in which the newborn infant is 
bathed should be 70° to 72° F. The bath-tub should be situated, 
if possible, near an open fire, to insure warmth. 

At birth the infant is covered with a white substance, the vernix 
caseosa, which must be carefully removed, and to this end the body 
is anointed with vaseline or olive oil, the latter being preferable to 
vaseline, which may irritate the skin. When the infant is anointed 
it should be exposed part by part only, in order to guard the 
body-temperature from being rapidly reduced, and care should be 
taken not to displace the ligature or roughly handle the stump 
of the cord, lest hemorrhage result. The first bath is, therefore, a 
scientific function ; it cleanses and protects the infant from present 
and future auto-infection. The w^ater in which the infant is bathed 
should be boiled, in order to destroy any extraneous source of infec- 
tion, for, as will be seen later, the bath-water has been the cause of 
epidemics among the newborn, especially in hospital service. In 
private practice this danger does not obtain to the same extent as in 
institutions. 

The function of bathing the infant should be performed rapidly, 
and at the same time in a painstaking and gentle manner. The 
water of the bath should be 100° F., and some additional warm 
water should be at hand in order that the temperature of the bath 
water may be maintained at this point. The infant is placed 
in the bath, and with glycerin soap rapidly w^ashed, and lifted out 
and placed in a warm blanket. The depth of the water in the tub 
should be just enough to cover the body. The head is supported 
above the water by the disengaged hand of the nurse. The infant 
cannot then slip out of the arms of the nurse. While in the bath 
the infant is constantly but gently rubbed, and when taken from the 
bath should not be blue or in the least chilled. Drying the infant is 
best performed on the knees of the nurse, part by part, so as not to 
expose the infant's whole body at one time. The cord is dressed as 
above described and the binder applied. All clothing, including the 
binder of the newborn infant, should be made of soft flannel or pure 
wool. 

Daily Bath. — There has been some discussion as to whether an 
infant should be bathed daily, after the first bath, before the separa- 
tion or falling off of the stump of the umbilical cord. It has been 
demonstrated that infants who are not bathed in the first week lose 
less in weight than those who are bathed. It is best, therefore, in 
order to avoid infection of the umbilical wound, to favor mummifica- 



PREMATURE INFANTS. 51 

tion of the cord, as well as to conserve the weight of the infant, 
not to give a full bath, after the first bath detailed above, until the 
umbilical wound has healed and the stump of the cord has separated. 
When this has taken place the infant is bathed daily ; up to that time 
it is washed twice daily, with a view to cleanliness. If the dressing 
on the umbilical stump has become soiled with urine, or otherwise, 
it is changed ; but unless this indication exists the first dressing is 
left undisturbed. 

The best time for the bath is in the forenoon, one hour after 
nursing. The temperature of the water of the infant's bath should 
not be below 99° or 100° F. during the first ten days ; 95° F. dur- 
ing the first month of infancy ; and 90° F. after the sixth month. 
It has been proposed — on grounds which are somewhat obscure and 
not founded on physiological facts — to harden the infant by means 
of a gradual reduction of the temperature of the bath-water until, 
even with an infant below one year, the bath- water is quite cool. 
Such a procedure does not harden the infant ; on the contrary, it has 
been shown that it is directly detrimental to his growth and well- 
being. Delicate infants, even those born at full term, may by such 
a process of hardening contract a bronchitis, or even some more 
dangerous affection of the lung. 

The details of the daily bath are much the same as those 
described with the newborn infant. The use of a sponge in bath- 
ing is not cleanly or desirable. A soft piece of linen or muslin or 
so-called washcloth is much to be preferred, as it can be easily 
cleansed and boiled. After the bath the infant is taken from the 
water and placed in a soft, warm blanket or bath robe, carefully 
dried and powdered. Powder is applied to the axillae, groins, but- 
tocks — where surfaces come in contact. The general surface of the 
body is not powdered unless some indication exists. 

Premature Infants, and Infants who are Under weight. — 
Infants born prematurely or those who weigh six pounds or less, 
even though born at full time, should not be bathed as above 
described, but are best washed part by part with warm water once a 
day until the weight has reached the normal limits. These puny 
infants are particularly susceptible to reduction of temperature. In 
fact, the rectal temperature in such infants is always low, and any 
bath, even a warm one, will reduce the temperature still more and 
may result in serious chilling of the body. 

Hardening". — It will be seen from what I have said that I do 
not believe in the so-called hardening process as applied to children. 
I have seen children, whose mothers took a pride in bathing them 
with cold water, who remained pale, stunted in growth, nervous, 
even with a flabby musculature, notwithstanding a daily regimen of 
cold water which was intended to have a tonic effect, both on the 
general nervous system and physical development of the child. In 



52 MANAGEMENT AND HYGIENE OF THE NORMAL INFANT. 

my experience I have rarely found, at least in this climate, that 
any other temperature for bathing was indicated but that which has 
been mentioned above. A very excellent guide as to the proper 
effect of any form of bathing on an infant is the so-called reaction 
in and immediately after the infant is taken out of the bath. In 
the bath and after bathing the infant should be warm on the surface 
and present a ruddy appearance. If during or after a bath the 
infant is cyanosed and the surface of the body is cool, we will con- 
clude that the bath, at whatever temperature it is given, is not 
adapted to the infant. 

Eyes. — In a maternity service, where numbers of women are 
delivered and there is danger of one infant being infected by 
another, it is customary to instil into each eye at birth a drop of a 
2 per cent, solution of nitrate of silver. This is done as a pro- 
phylactic measure against gonorrhoeal ophthalmia, a disease which 
has been proved to be a great etiological factor in the causation of 
bliudness. In private practice, however, this is scarcely necessary 
(see Ophthalmia Neonatorum), especially if we are acquainted with 
the condition of the mother and no vaginal discharge has been 
present previous to labor. If, however, there has been a vaginal 
discharge before labor, it is well either to apply the Crede method 
and instil a drop of a 2 per cent, solution of nitrate of silver into the 
eye, or to carry out the prophylactic measure of Kaltenbach, 
described in the section on Blenorrhoeal Ophthalmia. 

The eyes during infancy need no attention other than that cus- 
tomary in the adult — cleanliness. Any slight discharge from the 
eye indicates a conjunctivitis. The nearer this conjunctivitis occurs 
to birth, the more w^e should be on guard for detection of a gonor- 
rhoeal process. It is always wise, therefore, as soon as any secre- 
tion of pus is detected in the eyes of the newborn infant, to examine 
this pus for microorganisms of a specific nature. Any swelling of 
the conjunctiva or the lids should put us on our guard against gon- 
orrhoeal infection. 

Method of Taking the Body-temperature of the Infant. — 
The temperature of infants and children is always taken in the rec- 
tum ; but if the child is above five years of age we may, under certain 
conditions, take ah axillary temperature. Some children are terri- 
fied at the sight of a thermometer ; others have an innate mod- 
esty, which it is the duty of the physician to respect, and which 
precludes the taking of a rectal temperature. If the indication is 
not pressing, therefore, an axillary temperature may be taken in 
older children in the same manner as in the adult. 

It is well in dealing with children to teach the parents how to 
use the thermometer. In this way each child may have its own 
thermometer, whether it is used in the rectum, the axilla, or the 
mouth. This is not only convenient for the physician, but is 



DIAPERS. 53 

entirely proper, especially as applied to children, for thermometers 
cannot be thoroughly disinfected, and it is certainly objectionable 
for a physician to go from one little patient to another, introducing 
the same thermometer into the rectum. 

In introducing the thermometer into the rectum, the infant or 
child should be laid on the side. The bulb of the thermometer 
is anointed with vaseline or olive oil, the buttocks are gently sep- 
arated with the fingers of the left hand, and with the right hand 
the bulb of the thermometer is carefully insinuated into the rectum. 
The infant or child is continued on the side for at least three min- 
utes. The thermometer is then removed, and after reading the 
register the physician should carefully cleanse the thermometer, 
before proceeding further, with a piece of cotton first, then with a 
fresh piece of cotton moistened with ether and then alcohol, and 
finally with a 1 : 2000 solution of corrosive sublimate or a 0.5 
per cent, solution of formalin. In private practice this para- 
phernalia is not always at hand, and the physician can see at once 
the utility of teaching the parents to have a thermometer in the 
house for the use of the child rather than that he should imper- 
fectly cleanse his own thermometer and use it on another patient. 
In children's hospitals this question of individual thermometers is 
of great importance, and no children's service can be conducted 
without danger of infections arising unless each patient has his or 
her own thermometer. 

Temperatures should be taken in mild cases of illness and in 
convalescence three times daily ; in protracted and serious illness, 
such as pneumonia or typhoid fever, every three hours throughout 
the twenty-four. 

Diapers. — The diaper should be made of an absorbent material, 
such as well-washed soft muslin or linen, and should be about two 
yards square. It is first folded in the middle, then in three-cornered 
fashion, refolded, and thus applied to the infant. A diaper should 
not be covered with a rubber protection except during travel, inas- 
much as under these conditions the diaper becomes, if moistened, a 
species of poultice and intertrigo results, as well as eczematous erup- 
tions of the buttocks. Diapers should be applied warm and dry. A 
moist diaper will sooner or later cause a skin eruption. A diaper 
moistened with urine should not be dried and used again on the infant, 
for by this method the salts of the urine are crystallized in the meshes 
of the diaper fabric and will irritate the skin. Diapers when soiled 
should be placed in a covered utensil sold in the shops for this pur- 
pose. Before washing the diaper the excess of movement should 
be removed. Diapers should be boiled in an alkaline solution, 
generally of soda, and should be washed by hand and not with 
the mandril, otherwise the faeces and discharges cannot be removed 
thoroughly. 



54 MANAGEMENT AND HYGIENE OF THE NORMAL INFANT 

After a movement the child is dried gently with a piece of soft 
linen, sponges not being used, carefully powdered, and a new diaper 
applied. Diapers, if soiled, should not be put into a disinfecting 
solution. On the contrary, there is a positive objection to this, as 
diapers permeated with drugs may cause irritation of the skin of the 
buttocks. After changing the diapers, the nurse's hands and finger- 
nails should be cleansed with brush and file. This toilet of the 
hands and finger-nails is very important, even with breast-fed 
infants, since the neglect of this function will result in a contamina- 
tion of the breast nipple or food with fsecal bacteria. Even the 
infant's own faeces may cause serious intestinal disturbance if rein- 
troduced in the above manner into the stomach and intestine. 

Care of the Genitalia. — The care of the genitalia in male and 
female infants is quite important, and it is surprising to see how 
such a simple matter is neglected by the mother and nurse. In 
female infants and children during the bath the labia should be 
washed, gently separated, and the parts beneath laved with water. 
After the bath these parts should be carefully dried, but not pow^dered. 
It is a very common practice to powder the parts beneath the labia 
majora in female infants. This custom causes cousiderable irritation 
around the introitus vaginae, as a result of the powders settling on 
the parts. If these parts are not powdered, but simply dried after 
the bath, they will remain in a normal condition, and an accumulation 
of smegma will be avoided. 

In male infants the prepuce should be retracted daily and the 
parts bathed with ordinary water. In this way accumulation of 
smegma, and balanitis will be prevented. It is not necessary to use 
medicated solutions, such as boric acid, for this purpose. In boys 
the scrotum, buttocks, and adjacent parts should be powdered. 

Play; Fondling. — It must not be forgotten that the average 
infant's stomach is easily upset, and that any kind of pressure on 
the abdomen is often a very effective way of emptying the stomach. 
After feeding, therefore, the infant should lie quietly in its crib and 
not be handled or fondled. Unless this rule is followed, vomiting 
after nursing will quite frequently occur. 

It should be remembered that too much play is apt to tire an 
infant as much as it would an adult. Infants who are played with 
and fondled to excess are tired, restless, irritable, and sometimes do 
not sleep. There is no rule to be applied, but moderation is to be 
followed in these things as in all others concerning the infant's 
pleasure. 

Sleep. — An infant in perfect health spends most of the time in 
sleep when it is not nursing. Unless its attention is engaged by 
others, it will not play in the early months of infancy. After 
nursing, an infant falls asleep, generally on the breast. Therefore, 
if an infant cries or is restless after nursing, there is something at 



BED AND NURSERY. 55 

fault. Older children should sleep in the afternoon for one hour, 
after the midday meal. This should be especially insisted upon 
with children who have a nervous temperament. If such children 
do not attain an early habit of sleep in the afternoon they will be 
restless at night, and finally develop symptoms of neurasthenia. 
Children should not be allowed too much intercourse with adults, as 
this is also apt to have a deleterious effect. Children should play 
with children. Adults should limit their play and contact with 
children as much as possible. 

Bed. — The best bed for the newborn infant is one in the form 
of a bassinet. The infant certainly should not sleep in the bed with 
the mother or nurse, for, aside from the danger of so-called over- 
lying, the infant is liable to become infected with the discharges of 
the mother ; and in a breast-fed infant there is always a temptation 
to give the breast to the child at night whenever it is restless. Bad 
habits therefore result. Aside from this, an infant will be restless 
unless trained to sleep in its own bed. 

The mattress of the bed should consist of a hair cushion pro- 
tected by a rubber draw-sheet. Over this is placed a bed-pad, and 
over this the bed-sheet. After the fourth month an infant may be 
placed in a crib. For restless children cribs are made wdth high 
sides, so that they may not fall out. Rocking bassinets or cribs 
are undesirable. An infant accustomed to such a rocking-crib or 
cradle will not fall asleep unless rocked, and the mother or nurse 
becomes a slave to the crib. If a baby in early infancy cries without 
any apparent cause just as it is placed in the crib from the mother's 
or nurse's arms, it is best not to take it up immediately, for, unless 
this habit is broken in early infancy, an infant will refuse to be 
pacified unless taken up several times in the twenty-four hours. 

The physician may be consulted concerning the pillow for the 
infant, as to whether it should be made of hair or down-feathers. It 
is well for the young practitioner to know that a pillow made of 
the finest curled hair is really more comfortable than a down- 
pillow. When placed under the infant's head, the pillow should 
reach well beneath the shoulders, so that the head and shoulders 
are supported together. The custom of not using the pillow for the 
infant allows the head to come in direct contact with the mattress, 
a very uncomfortable position, and one which inevitably results 
with careless mothers or nurses in a slight erosion at the back of 
the head, over the occiput. 

So-called pacifiers made of rubber or muslin should never be 
used in the nursery. They are undesirable and unnecessary, and 
if not used will not be in demand. 

Nursery. — The temperature of the room in which the infant 
passes its days should be carefully maintained at from 68° to 70° F. 
Variations in the temperature of the room not only chill the infant, 



66 MANAGEMENT AND HYGIENE OF TEE NOUMAL INFANT. 

bat interfere with its growth and nutrition. Drafts are reprehen- 
sible. The air of the room should have no odor, and we should 
ventilate indirectly from another room which is warmed. Incense 
should never be used to cover up an odor. The nursery should be 
well lighted, as well as capable of ventilation. An open fireplace 
aids the ventilation considerably, and in damp weather dries and 
warms the atmosphere as well as ventilates the room. 

The floor of the nursery should be made of hard wood or painted 
and covered with rugs. Carpets are not hygienic. They must be 
swept in situ; whereas rugs can be taken out, dusted, and aired. 
The crib should be protected from the open window by means of a 
screen. During infancy, up to the twelfth month, the temperature 
of the nursery, both day and night, should be kept at the same 
point. There is no reason why the temperature should be lower at 
night than during the day, as is customary in the sleeping-room of 
the adult. When the infant is in the open air, the nursery should 
be thoroughly ventilated for at least an hour a day. With premature 
children, however, we must be more careful and keep the temperature 
at a slightly higher point than the above. Or, if we have the room 
at 70° F., such children should be aided in maintaining the body- 
warmth by means of warm bottles placed underneath the blankets 
in the crib, but not necessarily close to the body. 

Open Air. — The infant may be taken into the open air three 
weeks after birth in the summer season and four weeks after during 
the winter, early spring, and fall. I have consistently advised that 
four weeks after birth, if the weather is not too cold, the newborn 
infant may be allowed an outdoor airing. I have seen no bad results 
follow from this advice. If the weather is exceedingly cold, com- 
mon sense would dictate that all infants should be kept indoors. 
After this time a daily open-air exposure is always allowable in good 
weather, provided the infant be warmly clad, especially in the winter 
time, so as to run no danger of chilling. If an infant shows a ten- 
dency to be easily chilled when taken into the open — which can be 
judged by observing the color of the face and hands — warm bottles 
should be placed underneath the covers of the baby carriage. 

Infants should be protected from the direct rays of the sun, 
inasmuch as they burn and tan very readily. Tanning of the skin, 
or sunburn, is not necessary to the health of the infant. A physi- 
cian will frequently be asked whether sleeping in the open air is 
injurious to the infant. It certainly is not, provided the infant is 
well protected in the manner described above. Some infants fall 
asleep immediately on coming into the open. We could scarcely 
keep such infants awake, and nature simply indicates to us in this 
way that the open air is a tonic to the general nervous system. In 
large cities, both in summer and winter, the face should be pro- 
tected by a veil when the infants are taken into the open. In the 



MANAGEMENT AND HYGIENE OF TItE NORMAL INFANT. 57 

country this is especially necessary if mosquitoes and flies are in 
the vicinity. Children who are running about should not wear 
short stockings if the locality is infested with mosquitoes or insects. 
There is nothing particularly hygienic in the custom of wearing 
short stockings, and it exposes the children to the danger of infec- 
tion, not only by mosquitoes (malaria), but by dangerous insects, 
such as spiders. 

Clothing. — Body-binder. — It is customary to provide the new- 
born infant with a body-binder made of soft, white, thin Shaker 
flannel, five inches wide and sufficiently long to pass two or three 
times around the body. It should be secured with strings, and not 
with pins, nor should it be sewed on the body. It is useful at 
first in retaining the dressing of the cord in place, and later on in 
supporting the umbilicus during straining or crying. The binder 
is discarded when the infant first makes attempts to stand. This 
usually occurs at the seventh month. The binder then loses its 
utility, inasmuch as the umbilical opening is naturally closed and 
supported by the muscular action of the recti muscles. It is 
customary, however, to substitute for the binder, when it is dis- 
carded, a so-called knitted flannel band, sold in the shops for this 
purpose. 

Clothing. — The clothing of the infant should consist of a 
chemise of wool next the skin. Over this there should be a loose 
garment, either wool or flannel, reaching from the shoulder to below 
the feet, and sufficiently long to allow it to be folded upward. Gar- 
ments should not restrict the chest in the old-fashioned way. The 
chemise should be made of gauze weight in summer and slightly 
heavier in the winter. Some infants cannot tolerate the contact of 
wool with the skin, because it causes an eruption of sudamina ; in 
such cases it is well to place between the skin and the woolen gar- 
ment a fine-linen chemise. 

Skin. — The precautions which should be observed in drying the 
skin after the bath have already been mentioned. Dusting-powders 
that contain perfume should be avoided. Dusting-powder is applied 
with a puff of absorbent cotton in preference to a powder-puff. 
This absorbent cotton can be thrown away and a new pledget used 
at each dressing. To prevent caking, any excess of powder should 
be removed. 

If the skin is subject to sudamina in the summer, a handful of 
bran is added to the water, or, what is preferable, the bran is put 
into a gauze bag, moistened and expressed in the w^ater of the bath 
until the water becomes turbid. Salt water irritates the skin of 
these infants and should not be used. 

Mouth. — It was formerly customary to wash the mouth of the 
infant thoroughly either after each feeding in bottle-fed infants, or 
two or three times daily in breast-fed infants. There is really no 



58 MANAGEMENT AND HYGIENE OF THE NORMAL INFANT. 

scientific indication for doing this if the nipples of the bottles used 
for artificially fed infants are kept scrupulously clean ; and the 
mother's or nurse's nipple for the breast-fed infant be cleansed with 
a solution of boric acid before and after each nursing. The mouth 
of the breast-fed infant especially should not be frequently washed. 
If the breast nipple is kept scrupulously clean, sprue or stomatitis 
will be avoided. Before the eruption of the teeth, the natural 
secretions of the mouth are quite sufficient to keep the mouth clean. 
After the teeth have appeared they may be kept clean by washing 
once a day with a piece of lint or cotton moistened with boric acid 
solution. In the morning, after the bath, the mouth of the infant 
is carefully washed with a piece of absorbent cotton wrapped around 
the finger and moistened with boric acid solution. No force should 
be used, and no hard pressure exerted against the roof of the mouth 
especially, as in this way ulceration may result. 

Before introducing the finger into the mouth of the infant, the 
nurse should thoroughly cleanse the hand. In order to avoid the 
introduction of sprue into the mouth, the bottle nipples should be 
boiled once a day for ten minutes in a soda solution, and cleansed 
carefully with hot water after each nursing. In the intervals of 
nursing the rubber nipples are best kept either in a glass-covered 
jar or in a piece of absorbent gauze. It is well not to keep them 
in a solution of boric acid, as this is apt to become contaminated. 

It has been maintained by some that washing the mouth of the 
infant nursing at the breast is prophylactic against infection of the 
breast by bacteria of the infant's mouth. Aside from the fact that 
the bacteria which exist in the mouth of the newborn and young 
infant, before the eruption of teeth, are not pathogenic, no one has 
proved that they are capable of causing breast abscess. Epstein 
has shown conclusively that washing the mouth of infants is pro- 
ductive of infectious ulcerations of the mucous membrane of the 
buccal cavity, as well as the means by which extraneous infections, 
such as gonorrhoea and sprue are engrafted on the mucous mem- 
brane. 

In the newborn the production of buccal ulcerations as a result 
of a too diligent toilet of the mouth is not without great danger. 
It has been long acknowledged that bacteria may gain access to the 
circulation through these ulcerations and thus cause general sepsis. 



DRUGS AND OTHER METHODS OF THERAPY. 59 

IX. THE ADMINISTRATION OF DRUGS AND OTHER 
METHODS OF THERAPY. 

Children should receive drugs in an agreeable form, although 
some may take nauseous drugs with apparent indifference. Bulky 
mixtures or drugs which are apt to upset the stomach should 
not be prescribed. The author recently saw a severe enterocolitis 
set up by a cough mixture containing antimony. Drugs should not 
be administered in pill form to infants or children. Tablets are 
a ready means of administering certain drugs. They can be 
crushed and given in a teaspoonful of some indifferent fluid. 
Powders are also easily taken. They are put in a spoon, some 
fluid added to form a mixture, which is then administered. Quinine 
is given either in syrup of yerba santa or in chocolate powder 
and water ; or the child is given a piece of chocolate to eat, and 
then is caused to take the quinine immediately afterward. A child 
should never be forced to take a medicine. Much harm is done in 
this way. Certain drugs, such as opium in the form of the simple 
tincture or morphine, are not given to children under the age of 
two years. Atropine, of late advocated in cholera infantum, should 
not be given to infants and young children. They bear this drug 
badly. Jaborandi is badly borne, as is also apomorphine. Camphor 
is a very good cardiac stimulant. It is useful in collapse, but must 
be given cautiously in cases in which there is diarrhoea. In the 
latter disease the camphor is apt to irritate the stomach and gut. 
The coal-tar series, such as antipyrin, antifebrin, and phenacetin, 
are powerful depressants. In those cases of fever in which it is not 
possible to give baths to lower the temperature we are sometimes 
forced to administer these drugs. It is then well to combine with 
them some caffeine. 

If a child or an infant refuses to take a drug, it may be put 
in a teaspoon, the spoon held horizontally to the lips, and when the 
mouth is opened the spoon carried far back into the mouth and 
tilted. The spoon is held in the mouth until the act of swallowing, 
which must inevitably take place, is completed ; the spoon is then 
withdrawn. If this manceuvre is thus carried out, the fluid will not 
be rejected. Holding the nostril closed, and thus forcing the child to 
open the mouth, is bad practice. Patience and suasion can accom- 
plish as much in most cases. 

Digitalis is not given continuously, but is administered for two 
or three days, and when the pulse begins to show signs of lessened 
frequency its administration is suspended. Alcohol is well borne by 
children. I do not hesitate to administer it in cases of nephritis 
if the heart is weak. In the gastro-enteritis of nurslings the 
stomach is very intolerant of alcohol. It should not be given except 
in very severe cases with great prostration, as the vomiting is apt to 



60 DRUGS AND OTHER METHODS OF THERAPY. 

be aggravated. Much has been written concerning antipyresis and 
antipyretics in the treatment of the diseases of infancy and child- 
hood. The young practitioner can feel assured that high tempera- 
tures are well borne by infants and children. A temperature of 
106.5° F. (41.3° C.) in an adult, although of short duration, would 
cause great alarm, and rightly so. On the other hand, such a tem- 
perature in an infant or child does not necessarily threaten life, nor 
is it incompatible with recovery. A convulsion in some children is 
the direct result of a rise of temperature. Such a convulsion will 
not necessarily lead to others nor to epilepsy. The heart and kidneys 
bear long-continued high temperature well in comparison wdth those 
of the adult. The most trivial causes will cause a rise of a degree 
or two in the temperature of an infant or a child. Taking all these 
idiosyncrasies into consideration, it may easily be understood by 
the student and young practitioner why it is essential that methods 
of therapy should be modified before they can be applied to infants 
and children. A reduction of temperature from 104° to 102° F., 
even if it can be accomplished by a coal-tar derivative, does not 
cure the patient. Some diseases, such as measles, scarlet fever, 
pneumonia, and a host of others, run a course of high and low 
temperatures extending over a certain space of time. If an infant 
or child is attacked with convulsions following every acute rise of 
temperature, the parents should be warned of this fact. In these 
cases, as soon as a rise of temperature is noted, it should be com- 
bated by every means in our power. Reduction of temperature in 
such children at the outset of a disease is of the highest utility. 
It saves the nervous system from the shock of a convulsion. 
Hydrotherapy is, as a rule, the safest and most satisfactory antipy- 
retic measure at our disposal. 

The dosage of drugs for infants and children has received much 
attention. In practice we judge more by the action of a remedy 
than the quantity administered. The initial dose should be small. 
Infants under a year receive -jV^h of the adult dose, and at the age 
of one year yV^h of the adult dose is safe. At the fifth year -l^th, 
and at the tenth year i the adult dose is the rule. These figures 
are not absolute. Nitroglycerin if given in doses of less than 
2-|^^th of a grain has scarcely any effect on children five years 
of age. On the other hand, strychnine may be safely given in 
quantities of 2To^^^ ^^ ^ grain to infants, and y^o*^ ^^ ^ grain to 
children two to three years of age. It will be seen that if the 
hard-and-fast rule of division of doses according to age were fol- 
lowed, these drugs would necessarily be given in much smaller dose, 
and their action would be correspondingly inefficient. 

Hypodermic administration of drugs to infants and children pre- 
sents nothing peculiar, as compared with the same method applied 
to adults. 



HYDROTHERAPY. 61 

Hydrotherapy. 

The practice of hydrotherapy as applied to the adult must be 
somewhat modified before it can be carried out with the infant or 
the child. The reason for this is that the infant or child does not 
react so readily and cannot bear sudden changes of temperature so 
well as the adult. 

The Sponge Bath. — A rubber sheet is placed on the crib, and 
over this one layer of a small blanket ; the patient is then placed 
nude on this blanket and covered with another blanket. There is 
thus no undue exposure. A small basin of water at 80° to 85° F., 
with a dash of alcohol, is now brought alongside of the crib. 
With a small sponge or piece of soft folded linen the parts of the 
patient are sponged ; first one arm, then the other, then the trunk, 
and finally the lower extremities. As each part is exposed, the rest 
of the body is kept covered. This procedure is repeated until the 
body has been sponged for five or ten minutes. This method of 
hydrotherapy is especially suitable in acute rises of temperature of 
short duration and in mild cases of continued fever in which the 
temperature does not rise high. 

Cold Chest Compress. — Three layers of linen are cut so that 
they will envelop the trunk from the clavicles to the umbilicus. The 
general shape should be that of a shirt deprived of arms and open 
at the sides. On the outside of this linen compress there should be 
a compress of Shaker flannel cut in a similar manner. The com- 
press of linen is moistened with water at 80° to 85° F. With 
robust children the water may be at 70° F. The compress is wrung 
out and applied so that the neck, shoulders, and chest are covered 
as with a shirt. The flannel is now applied to the outside. The 
compress is moistened every hour with water at 70° to 85° F. and 
re-covered with the flannel. 

The cold pack is not so useful in the treatment of the febrile 
conditions of childhood. The method is similar to that followed 
with the adult, with the exception that the sheet is moistened with 
water at 80° to 85° F. In other cases the patient, after being 
wrapped in such a sheet, is rubbed by the attendant with ice on the 
outside of the sheet. The author has had no extensive experience 
with this method. 

The Full Bath.— The full bath, as advocated by Brand, is 
seldom carried out in the treatment of children. Children struggle 
against the bath, and if the temperature is too low, they become so 
depressed that it is difficult to rouse them. I therefore place chil- 
dren with typhoid fever, or pneumonia, or scarlet fever in a bath at 
100° to 105° F., and lower the temperature to 80° or 85° F., 
applying friction to the body constantly. After five or ten minutes 



62 DRUGS AND OTHER METHODS OF THERAPY. 

the patients are taken out of the bath and rubbed dry. Warm- 
water bottles are applied to hands and feet. 

In conditions of delirium and coma with a high temperature, in 
which the heart is weak, I have given baths at a temperature of 
105° to 108° F. The cases in which these baths are indicated are 
those in which any application of cold water causes cyanosis and 
collapse. I have seen infants suffering from bronchopneumonia, 
with high temperatures, in a condition resembling a rigor after a 
bath at 85° F. With these infants the warm bath acts as a cardiac 
stimulant and quiets the nervous symptoms. 

Hypodermoclysis. 

Hypodermoclysis is the injection into the subcutaneous tissue of 
either a 0.6 per cent, salt solution or the normal salt solution of 
Cantani (sodium chloride, 4 parts ; sodium carbonate, 3 parts ; 
water, 1000 parts). It is indicated in infants suffering from 
cholera infantum and in other exhausting states. Monti, who was 
the first to apply this mode of therapy to the infant, injects 100 to 
200 c.c. at a time. Epstein showed that smaller quantities — 10 to 
40 c.c. — are more beneficial and more quickly absorbed. Expe- 
rience teaches that large quantities of fluid injected subcutaneously 
cause extensive blood extravasations in exhausted infants and much 
subsequent pain. The solutions used should be freshly prepared and 
sterilized. Welch has reported cases of infection with Bacillus 
aerogenes capsulatus following hypodermoclysis. I have had one 
case, although every precaution was taken to avoid infection. 

A large antitoxin syringe, holding 20 c.c, is used. It should 
be carefully sterilized. 

From 20 to 30 c.c. of the solution are injected two or three times 
daily into the subcutaneous tissue of the lumbar region or abdo- 
men. Monti injects into the subcutaneous tissue of the abdomen. 
Massage should not be performed after injection, as it is very pain- 
ful and causes hemorrhages. The puncture wound is covered with 
a piece of sterile gauze. The main point is to inject small quantities 
of the solution at intervals of from four to six hours, and watch the 
effect. The action is that of a stimulant to the heart and the 
processes of resorption. Epstein showed that within a few hours 
after injection of salt solution the proportion of haemoglobin and 
red blood-cells was reduced. As salt solution has a dissolving 
effect on the red blood-cells, the injection of large quantities of 
the solution may be harmful. 



SYEINGING OF THE NOSE. 



63 



Syringing of the Nose. 

Instruments. — The best form of Fm. 7. 

syringe for this purpose is an olive- 
tipped glass syringe. Some forms 

are made with a soft-rubber tip. Nasal syringe, correct shape. 

The tip should be blunt, lest the nares be injured (Fig. 7). 
The solution used is generally a normal salt solution. 

Fig. 8. 




^J^tyien/ 



Method of syringing the nose in the upright posture. 



Method. — The infant or child is wrapped in a sheet or blanket, 
and held in the lap of a nurse, who holds a pus basin beneath its 
chin. The operator stands behind the patient. The syringe is held 
horizontally to the floor of the nares and the solution slowly injected 
into the nostril (Fig. 8). If successfully performed, the procedure 



64 



DRUGS AND OTHER METHODS OF THERAPY. 



results in the solution's coming out of the other nostril. There is 
no danger in the manoeuvre if carefully carried out. If the infant 
is too weak, the nares may be syringed with the patient in bed in 
the recumbent posture. The nurse stands at one side, and the head 
is placed on the side, the pus basin beneath the nose, as shown in 
Fig. 9. A rubber fountain-syringe may be used in the same manner. 



Fig. 




Method of syringing the nose in the recumbent posture. 

Here also the position of the syringe is horizontal to the floor of 
the nares. The syringe should be thoroughly boiled before and 
after using. An old syringe should never be used, no matter how 
carefully it has been sterilized. 



Vapor Spray; Calomel Inhalations in Acute Laryngeal 

Disease. 

With infants and children the spray is not so useful an agent 
as steam vapor impregnated with balsams or turpentine, and 
combined at times with inhalations of the fumes of sublimed 
calomel. The spray cannot, as a rule, be used locally except 
with the most tractable children. With infants its use is not 
feasible. 

The vapor of steam impregnated with balsams or turpentine is 
very useful in all forms of acute laryngitis in which there is no 
bronchitis. I dispense with steam vapor if bronchitis is present. 
The mode of application in catarrhal or membranous croup is as 
follows : The crib is covered with a sheet suspended from four 



< 
.J 




iSTOMACH WASHING. 



65 



Fig. 10. 



upright poles fastened to the corners of the crib. A tent is thus 
formed. The croup kettle is placed at one side of the crib, in such a 
manner that the steam vapor escapes into the improvised tent. The 
vapor is medicated by placing in the 
kettle a teaspoonful of turpentine or 
thymol. This will be readily vapor- 
ized. No special apparatus has any 
advantage over the ordinary croup 
kettle. If calomel sublimations are 
to be given, they should be combined 
with the steam vapor. Ten grains of 
calomel are placed in a spoon held 
over an ordinary candle, and the 
fumes led under the tent, the air of 
which is impregnated with steam va- 
por. The special devices sold for the 
sublimation of calomel may be used, 
but possess no advantage over the 
method described above (Fig. 10). 
Calomel sublimations are exceedingly 
irritating, but they relieve the patient 
very promptly. They may be con- 
tinued for forty-eight hours at intervals of two hours, without 
fear of salivation. 




Sublimer for calomel inhalation. 



Stomach Washing. 

One of the most valuable additions to our therapeutic armament 
within recent years is stomach washing in case of the nursing infant. 
No improvement has been made upon the method as first proposed 
by Epstein. The cases in which it is indicated are mentioned in 
another part of this work. The procedure is easiest of application to 
nurslings in whom there are no teeth or in whom very few teeth 
have erupted. With these subjects there is no danger of the catheter's 
being bitten, and there is no necessity of using a gag. With older 
children, however, a gag must be used when stomach washing is 
attempted. The Denhardt gag of the O'Dwyer set of intubating 
instruments is most suitable for this purpose. 

Indications. — Washing out the stomach is principally indicated 
in the acute gastro-enteritis of the summer months. It is not bottle- 
fed infants alone that are attacked, but even breast-fed infants may 
be thus affected. The winter months also furnish their quota of 
these cases. One vomiting spell, as it is called, does not require 
attention. If, however, on suspension of the bottle or breast, vom- 
iting continues and becomes uncontrollable, we proceed to stomach 
irrigation. Another indication is the so-called chronic dyspeptic 



66 



DRUGS AND OTHER METHODS OF THERAPY. 



vomiting. Those who advocate this method of treatment in these 
cases forget that, above all, the food is at fault, and must be regulated 
and modified. I do not favor washing the stomach in these cases. 

One washing is, as a rule, sufficient. I have rarely had to 
repeat it. If vomiting persists after the first washing, it is well to 
look for other conditions than gastro-enteritis, such as intussuscep- 
tion, as the cause of the vomiting. 

Acute drug poisoning or ingestion of any irritating fluid is quickly 
relieved by stomach washing. I have washed out many children 
who had been given an overdose of paregoric, or who had taken 
Paris green, turpentine, or other drug. If, as sometimes happens, a 
child accidentally swallows a caustic alkali, we should not introduce 
the tube into the oesophagus or stomach. 

Method. — A four-ounce funnel, a piece of rubber tubing two and 

Fig. 11. 






=:^'^ 



Apparatus for washing out the stomach. 



a half feet long, and a No. 14 rubber catheter are the instruments 
necessary. The rubber tubing is attached to the funnel, and by 
means of a piece of glass tubing to the catheter, as in Fig. 11. 
About a quart of normal saline solution is needed. The temperature 



GAVAGE. 67 

of the water should be at least 100° F. The operator needs one 
assistant. The infant is completely undressed, and is then wrapped 
in a blanket, the diaper having first been applied. The hands are 
tucked in with safety-pins. The infant having been laid recumbent 
on a table, the operator, standing on the right, introduces his left 
index finger into the mouth and depresses the tongue (Plate L). 
The catheter, moistened with water, is now introduced and passed 
backward. With gentle urging the catheter passes easily into the 
oesophagus. There is no likelihood of the catheter's passing into the 
larynx and trachea. About six inches of the catheter are intro- 
duced. The funnel is depressed and the stomach contents are first 
allowed to flow out. The funnel is then raised about two feet 
above the patient, and the assistant slowly pours the saline solution 
into the funnel, the fluid flowing into the stomach. Before the 
funnel is completely emptied, it is lowered and the stomach contents 
siphoned out. This operation is repeated several times, until the 
water returns quite clear. If during the stomach washing the fluid 
should be ejected from the stomach in the act of vomiting, it will 
easily flow out of the mouth if the infant is recumbent. There is 
not the slightest danger of aspiration of the fluid into the trachea. 
I think the recumbent position is superior to the sitting posture advo- 
cated by some clinicians. A young infant is unable to sit up of its 
own accord. The introduction of the tube is not so easy for the 
infant in the sitting posture as in the recumbent position. The tube 
being introduced, the stomach contents sometimes refuse to flow out 
because mucus and food particles obstruct the lumen of the catheter. 
In such cases the catheter is withdrawn, and washed out. The cathe- 
ter is then pinched with the fingers in such a manner that some of the 
water or washing solution remains in the catheter. It is then intro- 
duced into the stomach. In this way the catheter, being filled Avith 
fluid, mucus and food cannot obstruct the lumen of the tube before 
siphonage is begun. Fluid can then readily be introduced into the 
stomach. These difficulties occur in cases in which there is a large 
amount of mucus in the stomach. The finger should always be 
retained in the mouth. By grasping the catheter with the thumb 
and index finger of the right hand, prying open the mouth at the 
same time, we prevent pressure on the catheter during the washing. 
If the infant has upper and lower incisors, the catheter must be held 
at one side of the mouth and the mouth kept open by means of the 
index finger held in the angle of the mouth. The method described 
above has been followed by me for years. I have never had an 
accident. 

Gavage. 

Gavage is a method of forced feeding by means of the stomach- 
tube. I have not practised this method of feeding infants. Older 



68 DRUGS AND OTHER METHODS OF THERAPY. 

children suffering from pneumonia or typhoid fever, and delirious 
or unconscious, have been fed with success by this method in my 
wards. 

The method of procedure is similar to that used in stomach wash- 
ing. It is best not to introduce the catheter through the nose, but 
to keep the mouth open with some device. If the catheter is passed 
through the nose, no food should be introduced into the funnel until 
we are sure the feeding- tube is in the stomach. With older children 
a tube passed through the nose may pass into the larynx. If it 
has done so, a hissing sound will be heard. Aphonia will also be 
present. In infants and young children the glottis is small, and a 
full-sized catheter will not readily pass into it. After the tube is 
in the stomach the prescribed amount of liquid food is introduced 
and the tube rapidly withdrawn. The feeding may be repeated every 
four to six hours. 

Rectal Enemata; Irrigation; Enteroclysis. 

The bulk of an ordinary enema, introduced in order to empty 
the bowel, should be from 2 to 4 ounces. A Davidson's bulb 
syringe should not be used. A No. 16 or No. 18 catheter is attached 
to the nozzle of an ordinary four-ounce hard-rubber syringe. The 
infant or child is placed on its side, with a rubber sheet under the 
buttock. The tij) of the catheter is oiled and passed well within 
the anal ring. The catheter is then attached to the nozzle of the 
syringe containing the fluid to be injected, and the fluid is gently 
thrown into the rectum. An enema commonly used is soap- water, 
with the addition of a tablespoonful of castor oil or glycerin. 

The high rectal enema, irrigation, or enteroclysis, is given in 
all forms of summer diarrhoea, dysentery, and in typhoid fever. It 
is also indicated in cases in which there are symptoms of collapse, in 
exhausting diseases, in nephritis, and after operations. It is also 
used to reduce intussusception. In diarrhoea, the object of the high 
rectal enema is twofold — to clear out the feces from the lower 
bowel, and to supply fluid to the depleted circulating blood, thereby 
stimulating the heart. The latter is the main object in practising 
enteroclysis in states of exhaustion and after operations. In sup- 
pression of urine we aim to supply fluid to the kidneys and stimu- 
late the circulation. According to Kemp, the high rectal enema 
is one of our most useful diuretics. 

The solution employed is the Cantani saline solution (sodium 
carbonate, 3.0 ; sodium chloride, 4.0 ; water, 1000). At least a 
quart is injected. The temperature of the solution for simple wash- 
ing of the gut, as in diarrhoea, should be that of the body. In 
nephritis or collapse the temperature should be at least 108° to 
110° F. (42.2° to 43.3° C). 



< 

Oh 




o 

3 



RECTAL ENEMATA; IRRIGATION; ENTEROCLYSIS. 69 

The instrument employed may be a bag fountain syringe, of a 
quart capacity, to which is attached a small calibre soft-rubber 
rectal tube or a catheter, or the rubber tubing and catheter may be 
attached to a six-ounce glass funnel. 

The patient is completely undressed and laid on a table on the 
side, with the knees flexed and the buttocks near the edge. A 
rubber sheet placed underneath the buttocks leads into a pail, so that 
the returning water will drain off (Plate II.). The buttocks are 
placed slightly higher than the trunk. The catheter or rectal tube 
is oiled and introduced two or three inches into the rectum, the water 
allowed to flow, and the tube passed higher up. Sometimes there is 
an obstruction to the passage of the tube, and then it is necessary to 
introduce the finger cautiously into the rectum alongside of the tube 
and guide it past the upper sigmoid ring. The tube may thus be 
passed from six to eight inches into the gut. It is seldom necessary 
to introduce it higher, as the water will find its way into the colon. 
About a pint or more of water is then allowed to flow into the gut. 
It is not necessary to compress the anus around the catheter to pre- 
vent escape of the fluid. Some of the fluid may escape alongside 
the catheter. In some forms of exhausting diarrhoea a portion of 
the saline solution should be left in the gut after it has been well 
irrigated, in order to stimulate the heart and supply fluid to the 
circulation. Two irrigations may be necessary in the twenty-four 
hours, rarely more. In typhoid fever one low irrigation is given 
daily. In some subjects, if the irrigations are continued too long, 
hypersemia of the mucous membrane results. Clinically, this is 
manifested by a continuance or increase of mucus in the washings, and 
also by the occasional presence of blood. In such cases the enemata 
must be suspended. In nephritis complicating scarlet fever, rectal 
irrigation is one of the recognized methods of stimulating the secre- 
tion of the kidney, which result, according to Kemp, begins twenty 
minutes after the fluid is introduced into the gut. With adults the 
Kemp tube is used, but with children, who are difficult to keep 
quiet, continuous irrigation is not feasible. In these cases high 
enteroclysis is given in the ordinary manner, as much of the solu- 
tion as possible being retained in the rectum. This procedure may 
be repeated two or three times daily. In giving ordinary entero- 
clysis the bag of the fountain syringe or funnel should not be held 
more than three feet above the body of the patient, lest the pressure 
be too great. About a pint of fluid at a time is allowed to flow into 
the gut ; the catheter is then disconnected, and the contents of the 
gut allowed to flow out. 

A stimulating enema is given after an operation, or when symp- 
toms of collapse appear in any acute illness. Only small quantities 
of solution are allowed to flow into the rectum. A formula in use 
in my wards is the following : 



70 DRUGS AND OTHER METHODS OF THERAPY. 

Whiskey 3J. 

Caffeine gr- i- 

Tinct. digital gtt. ij. 

Sol. sodium chloride (0.6 per cent.) 5J. 

Temperature, 102°-105° F. 

Nutritive enemata are used when for any reason, such as uncon- 
trollable vomiting, the stomach must be given complete rest. Soma- 
tose solution, of one teaspoonful of soraatose dissolved in eight 
ounces of cold water, is given lukewarm oij at a time, every four 
hours. Or, ext. pancreatis, gr. v ; sod. bicarb., gr. ij ; water, ,liv ; 
milk, 5xvj ; with or without the addition of an egg. Give lij or 
5iij. These enemata should be given slowly and high up, and in 
small quantities at a time. 

For constipation the following is excellent : 

Olive oil 5ij. 

Glycerin 3j. 



SECTION II. 

INFANT FEEDING. 

I. PRINCIPLES UNDERLYING THE PROCESSES OF 
NUTRITION. 

There is no division of pediatrics which exceeds in importance 
that of infant-feeding. In fact the subject of infant-feeding is 
not only difficult to master, but requires thorough study and experi- 
ence to carry it to a successful issue. The practitioner, therefore, 
will find that it is absolutely necessary for him to understand the 
principles underlying the art of infant-feeding, in order to attain 
any success in practice in this field. Though great advances have 
been made in the study of infant-feeding in the past decade, we 
cannot say that the art of applyiug certain principles of nutrition 
to the feeding of infants has attained its highest perfection. We 
cannot explain why one infant will thrive, whereas another, fed 
according to the same method, will fail to thrive and lose ground. 
To a certain extent, therefore, the subject of infant-feeding is still 
empirical, although it may be said that empiricism is gradually but 
surely disappearing from this field of pediatrics. It is the excep- 
tional infant which to-day refuses to thrive, and puzzles the most 
brilliant master of the art, but the vast majority of children can 
certainly be fed according to principles well established and laid out 
at the disposal of the general practitioner. 

If we study these principles of nutrition closely we shall see 
that they must to a certain extent conform to what is known to take 
place not only in the body of the infant, but also in that of the 
adult. There are certain exceptions which must be made as regards 
the infant, on account of its rapidly growing organism and the fact 
that the cells of the body are not only being replaced rapidly, but 
the tissues at the same time are undergoing rapid increment. As 
that of the adult, the body of the infant and child is constantly 
suffering a loss of its principal elements, consisting of water, albu- 
min, fat, and mineral salts. This loss will vary within wide limits, 
according to the needs of each individual subject. The infant body 
must take in sufficient nourishment not only to make up for the 
constant loss and destruction of cell life, but also for the increase 
and growth of the body and development of various tissues, in this 
respect differing from the adult. The loss of nitrogenous sub- 
stances and fat must be made up by equivalents in the food ; at the 

71 



72 PMtNClPLES UNDERLYING THE PROCESSES OP NVTPITION. 

same time in the infant and child enough must be furnished to 
allow for the rapid increase of weight and the growth of tissue 
throughout the body. 

There are other substances, such as collogen, chondrogen, ker- 
atin, mucin, and lecithin, which are needed in the infant's economy 
as well as in that of the adult, and these are excreted by the infant 
and child as in the adult. If fat and albumin are taken in sufficient 
quantity into the system, the loss in these substances is compensated for 
by the splitting up of the nitrogenous and fatty elements of the food. 

It will enlighten the student to familiarize himself with the role 
played by the various food elements in replacing the loss of tissue 
in the economy. These primary food elements are principally 
water, mineral salts (inorganic and ash residue), proteids, or albu- 
min, fat, and carbohydrates. 

Water. 

Water plays by far the principal role in the composition of 
the body. The tissues of the body contain from (j6 to 70 per 
cent, of water in the newborn infant and child, as compared with 
64 per cent, in the adult. It exists in this high percentage in 
most of the organs of the body, with the exception of the bones, 
cartilage, teeth, and fatty tissue. The remaining organs, if these be 
excluded, will contain 78 per cent, of water. Water is not only 
essential to the adult body, but is a very important element of 
nutrition in infants. We see this exemplified in disease, especially 
when the drain on the system is great and the loss of fluids of the 
body is considerable, as in cholera infantum, or in intestinal disease, 
acute and chronic. Infants show the drain of water from the 
economy very rapidly, and our treatment in disease is directed in a 
great many instances to supplying the loss of water caused by the 
diseased condition. The circulation of the blood and lymph 
depends on the presence of a fixed percentage of water; in the 
former case 78 per cent., in the latter 96 per cent, of these tissues 
is composed of water. Digestion, both in the adult and the child, 
must have for its successful completion a certain amount of watery 
element. Muscular and nerve force are greatly dependent on water 
and are regulated by it. 

The body excretes water through the urine, the faeces, the lungs, 
the skin, and the amount excreted varies widely, not only in the 
adult, but in the infant and child. 

It is not our aim here to enter into any specific details of the 
role played by water in the economy, but from what has been said 
it can be seen that inasmuch as fully 86 per cent, of the breast-fed 
infant's food consists of water, nature has put great store by this 
element of foodstuff which is taken into the infant's body daily. 
Moreover, water given in disease will sometimes maintain life, but 
it cannot maintain the proper nutrition of the body without the 



pnoTEins. 73 

addition of other elements of food. This is seen in the treatment 
of gastro-enteritis. We may tide over a critical period in the dis- 
ease by the administration of water exclusively, without endanger- 
ing life through starvation. During this period, however, the nitrog- 
enous waste of the body is not replaced by any equivalent article 
of food, and though we may continue on a water diet for a little 
while, it becomes imperative after a time to add other substances to 
the food. 

Mineral Salts. 

Mineral salts exist in most of the tissues of the body and in all 
organized tissue which, when burnt, leaves an ash residue. Sodium, 
potassium, lime, magnesium, and phosphorus, with a trace of iron, 
are the principal mineral substances found in the body. Just as 
water is necessary to the maintenance of the nutrition of the body, 
so are the mineral salts. The actual growth of the child in the 
first six months amounts to 150 to 300 grammes ; in the following 
six months, 100 to 200 grammes per week. In the second year 
the body-weight is increased by 50 to 100 grammes per week, and 
from this time on the increase declines. The skeleton in the first 
year increases fully 2.2 pounds, or one kilo, in weight, and the 
earthy phosphates being an important element in the composition of 
the bones, 3.5 grammes of phosphate of calcium are used every 
week during the first year by the skeleton. This great demand of 
the skeleton for lime salts is met by the food of the infant — the 
milk — much better and in a more assimilable state than by any food 
taken by the adult subject. The muscles also need a certain amount 
of lime salts, and a dearth of mineral salts becomes evident much 
more quickly in the infant and child than it does in the adult. We 
see this exemplified in artificially fed infants, whose food (cows^ 
milk) is not as well assimilated as is the mother's milk by the nat- 
urally fed infant. Whereas 800 c.c. of mother's milk contain 1.2 
grammes of potassium phosphate, 0.2 grammes of lime phosphate, 
0.6 grammes of sodium chlorid, and 2.5 milligrammes of iron, and 
these are completely assimilated by the infant, the same salts in 
cows' milk are excreted to a great extent by the intestine (Bunge), 
and for this reason, in part, rachitis and disturbances of nutrition of 
the bones are very common in artificially fed infants. 

Proteids. 

Next to water, according to Munk, the most important constitu- 
ents of the body are the proteids ; they make up 10 per cent, of the 
tissues. The proteids in the food not only replace the general 
nitrogenous loss of cell tissue in the body, but with other substances, 
the so-called proteid-saving elements of the food, such as fiit, add 
to the general nitrogenous store in the body. Nitrogenous cell 



74 PRINCIPLES UNDERLYINO THE PROCESSES OF NUTRITION. 

waste can be replaced only by the proteids of the food. Growth of 
body is accomplished by the proper supply of albumin in the food. 
Whereas other substances, such as fat, added to the albuminous 
substances of the food may replace nitrogenous waste in the body ; 
increase of weight or growth can be accomplished only by the pro- 
teid elements of the food. The bone tissue, cartilage, tendon, con- 
nective tissue, need proteids also, as has been stated above, to 
replace the waste and accomplish the growth of these tissues. The 
breast-fed infant obtains in its food a casein and also, in small quan- 
tities, lactalbumin. From these the body forms not only the nitrog- 
enous cell elements, but mucin, chondriu, glutin, elastin, keratin, 
which are derivatives of albumin, and whose mode of formation is 
still obscure (Munk). 

Fats. 

Animal fats are composed of varying proportions of olein, 
palmitin, and stearin. Their presence in the body varies, within 
certain limits, from 9 to 23 per cent, of the body-weight. Fat is 
found in the body in the form of fat-deposits. It is deposited 
underneath the skin, in the muscle, in the nerve tissue, around the 
various organs of the body. It plays an important role in the 
maintenance of the ^^ armth of the body and exerts a non-conduct- 
ing role, preventing radiation. As a food it cannot replace the pro- 
teids. Fat combined with proteid substances in the food may, how- 
ever, act as a nitrogenous-saving substance. Thus, in muscular 
work the body needs a great amount of fat. If combined with the 
proteids, nitrogenous waste is saved and fat is burnt up in doing 
the muscular work, and it may even, if taken in sufficient quanti- 
ties, cause an accumulation of fat in the body. To cause growth in 
nitrogenous tissue, however, the presence of a sufficient amount of 
proteid in the food is absolutely necessary. Thus, while fat and 
albumin may replace waste caused by muscular action, both in 
the fiitty and nitrogenous tissues of the body, fat cannot add to the 
nitrogenous growth of cell tissue. The infant and child obtain the 
fatty elements of the food in the milk. Whereas 97.5 per cent, of 
the fat in mother's milk is assimilated, only 93.5 per cent, of the 
fat of the cows' milk is assimilated by the infant. The artificially 
fed infant, therefore, is deprived of an important food element to 
the extent indicated, and in many cases assimilation of fats in 
the artificially fed infant is even much more imperfect in practice 
than is indicated by the percentage named. For we note that in 
some infants, if the fat in the cows' milk is increased beyond a cer- 
tain percentage, certain symptoms of intestinal indigestion manifest 
themselves in a so-called fat diarrhoea, and it is a common observa- 
tion that such infants must be fed on a limited amount of fat 
because of the difficulty of assimilation of fat of cows' milk. 



CARBOHYDRATES 75 



Carbohydrates. 



According to Mimk, carbohydrates exist in various tissues of 
the body, most abundantly in the liver, in the form of glycogen and 
grape sugar ; in the human milk, in the form of milk sugar, 3 J to 
9 per cent., in the muscles, in the form of glycogen, 0.3 to 0.9 per 
cent., with some grape sugar. The blood and lymph contain a 
small quantity of grape sugar (0.1-0.15 per cent.). We find gly- 
cogen in all growing tissues, and the formation of glycogen seems to 
be a function of the young cell. 

The infant obtains its carbohydrates for the most part from the 
milk, where they exist in the form of milk sugar. Milk sugar as 
contained both in human and in cows' milk is assimilated by the 
infant completely, so that in this respect the infant is not deprived 
in artificial feeding of any food element. 

Carbohydrates play much the same role in the economy as do 
the fats in saving nitrogenous waste. Whereas we can make up 
to a certain extent nitrogenous waste by the addition of fats and 
carbohydrates to the food, the nitrogenous substances of the body 
themselves can be reproduced only by nitrogenous proteid sub- 
stances. It is self-evident, therefore, that in infant-feeding, though 
we may produce fat by carbohydrates, saving to a certain extent 
nitrogenous waste, we cannot do this for any length of time without 
producing an actual proteid starvation unless Ave supply with the 
carbohydrates and the fat a certain amount of proteids. We see 
this well illustrated in substitute infant-feeding in cases of difficult 
proteid digestion. We can aid digestion of the proteids by the 
addition of carbohydrates. We can even cause the formation and 
deposit of fat to a great extent by the addition to the food of car- 
bohydrates. We can save nitrogenous cell waste by the addition 
of carbohydrates to the food. If we continue this mode of feeding 
for any length of time we can see clinically the effects of the dearth 
of proteids on the economy. The infants after a period of time do 
not increase in weight, the tissues of the body suffer in nutrition, 
and anaemia appears. We then must supply with the carbohydrates 
an increased amount of proteids. 

II. METABOLISM IN THE NURSING INFANT. 

The principles of metabolism and nutrition which have been 
established in the adult apply in a general way to the nursing 
infant. In the adult the food supplies the waste and maintains 
body-heat and energy, but in the infant it must also furnish, in 
addition to these, the material for body-growth. The main physio- 
logical characteristic, therefore, of infancy and childhood is that it is 
a period of growth, and the younger the infant the greater the growth. 

Milk, the food of the breast-fed infant, contains all the necessary 
food elements to maintain nutrition, produce energy, warmth, and 



76 METABOLISM IN THE NURSING INFANT, 

to aid in cell-growth. In considering metabolic processes in the 
infant we express the energy and warmth-producing equivalents of 
the food introduced into the body by the term calories. A calorie 
is the heat produced by raising 1 kilogram of water, 1° C, and 
is the unit of heat. In the infant there is a deficit, as in the adult, 
of 10 per cent, between the raw calories (food) introduced into the 
body and the actual number of calories produced. In other words, 
all the food is not absorbed. We do not know as yet how much to 
allow in estimating the number of calorie equivalents for the 
excreta, urea, carbonic-acid gas, and water. With the above defects 
yet to be elucidated by further investigations, we can present the 
following facts : 

A breast-fed infant, three months of age, weighs 5 kilos, takes 
800 c.c. of breast milk in the twenty-four hours, and increases 0.25 
to 0.35 grammes a day. A litre of human milk contains ; casein 
16 grammes, fat 35 grammes, milk sugar 65 grammes. The adult, 
on the other hand, takes daily 1.7 of proteids, 0.85 of fat, 7.5 of 
carbohydrates per kilo of body-weight. The nursing infant, there- 
fore, takes per kilo of body-weight twice as much proteids and three 
times as much fat as the adult, the milk sugar being converted 
into fat values. In the adult the ratio of proteid to other food 
substances is as 1 to 5 in the food ; whereas in the infant taking 
human milk the ratio is as 1 to 6, and with cows' milk, 1 to 3. 

According to Rubner, the caloric value of 1 gramme of proteid 
substance of the milk is 4.4, 1 gramme of milk sugar, 3.9 calories, 
and 1 gramme of fat, 9.2 calories. One litre of human milk is 
equal to 650 calories, and 1 litre of cows' milk to 700 calories. 
An infant three months of age, therefore, drinking 800 grammes 
of breast milk would take in 500 calories daily, and if it weighed 
5 kilogrammes it would be taking 100 calories per kilogramme of 
body-weight a day. Bonnoit found by experiment that an infant 
produced 80 calories per kilogramme of body- weight in twenty-four 
hours, and if we deduct 10 per cent, from the raw caloric equiva- 
lent of the food we would have almost as many calories introduced 
into the body as the body produced. 

The need of 100 calories per day remains constant during the 
first year of life, diminishes slightly in the second year, with the 
following exceptions : During the first ten days the infant uses up 
only 40 to 50 calories, and the increase of weight is accomplished 
mostly by the watery substances of the food. Rubner and Heub- 
ner found that of the 100 calories used up daily by the infant, 20 
were utilized to supply body-waste and 80 were burned up to pro- 
duce heat. Therefore the necessary heat-producing calories are 
much higher in the infant as compared to the adult, as are also the 
number of calories necessary to increase body-weight. This greater 
need on the part of the infant is explained by Rubner by the fact 
that in proportion to their body-weight, infants present a greater 



EXCRETA. 77 

surface area than do adults, and therefore lose much more heat in a 
given time than does the adult subject. Therefore the extent of 
loss of heat is dependent on the extent of surface exposed, and 
allowing for this and not calculating the needs of the the organism 
by weight, we find that both the child and the adult need the same 
number of calories. 

The following shows the number of calories produced by the 
various constituents of the food in the adult and in the infant. 

Of 100 calories in the food taken in by the adult, proteids pro- 
duce 19, fats 30, carbohydrates 51. Of 100 calories in the milk 
taken by the infant, proteids produce 18, fat 53, carbohydrates 29. 
In the infant, therefore, the fat is the chief heat producer. It is 
also nitrogen-saving, inasmuch as the latter is used for cell-growth. 

After the first year growth is not so active and less fat is needed, 
and this constituent is replaced by the carbohydrates. The follow- 
ing table illustrates this : 

Weight- 
Age, kilogrammes. Proteids. Fats. Carbohydrates. 

3 days 3.0 2.4 2.8 2.9 

6 '' 3.2 3.7 4.3 4.4 

4 months 6.0 3.8 4.5 4.6 

1^ years 9.0 4.4 4.0 8.9 

21"" 10.0 3.6 2.7 15.0 

11 " 23.4 2.8 2.0 11.4 

Adult 70.0 1.7 0.85 7.5 

Mineral Salts. 

The infant in its milk takes more mineral salts into the body 
than the adult, kilo for kilo of body-weight. They are utilized in 
the growth of the infant. 

Excreta. 

Much is to be learned as to how much should be allowed to the 
excreta in calculating the necessary calories used up by the infant 
organism. By the excreta we mean urea, water, and carbonic acid 
gas. Rubner and Heubner have shown that an infant in the first 
six months excretes less urea than the adult. In the second half 
year the infant excretes more urea than the adult, and this increases 
until the tenth year. In proportion to its weight the infant takes 
more nitrogenous substance into the body than it excretes in the 
form of urea. 

During the first six months, the growth of the infant being most 
active, this is most markedly so, and the nitrogen is retained to a 
greater extent in the system during the first six months of infancy. 
Michael has found that the nitrogen excreted in the faeces and urine 
and the proteids of the food retained in the body were one-fourth 
of the whole increase of weight in the newborn infant. 



78 METABOLISM IN THE NURSING INFANT. 

Water. 

Rubner and Heubner found that of 530 grammes of water taken 
by the ten-weeks-old child into the body, 505.5 grammes were 
excreted, and of this quantity more than half was excreted in the 
form of urine. 

Carbonic Acid Gas (CO^.) 

Voit, Pettenkofer, Forster, and Mensi have shown that from 
birth to the tenth year of life the child excretes one and a half to 
two and a half times as much carbonic acid gas as the adult, and 
this is practically furnished by the fats. Rubner, Heubner, and 
Bendix, however, have shown that a breast-fed infant weighing 5 
kilos (11 pounds) exhales per square metre of body-surface less 
COg than the adult. 

Munk thinks that the proteids are utilized in the organism to 
form carbonic acid gas. The principal facts, therefore, adduced in 
regard to the breast-fed infant in connection with metabolism are 
that the infant in the course of the first six months needs for the 
production of warmth, potential energy, and increase of weight 100 
calories per kilo of body-weight. Eighty of these calories are util- 
ized for warmth and energy and 20 for increase of cell-growth. If, 
therefore, an infant takes only 80 calories into its body, its weight 
will remain stationary. If it takes less, it will have to utilize its 
own tissues in order to live, and emaciation will result. 

Metabolism in the Bottle-fed Infant. 

What has been said of the nursling at the breast applies in a 
general way to the bottle-fed infant, with the exception that Rubner 
and Heubner have shown that an artificially fed infant needs 120 
calories instead of 100 per kilo of body-weight to maintain warmth, 
energy, and increase in weight. They explain the need of the addi- 
tional 20 calories taken into its body by the bottle-fed infant by the 
necessity of extra work on the part of the intestine in digesting 
cows^ milk. It is of interest that the infant, notwithstanding the 
fact that cows' milk is so entirely different in its composition from 
human milk, can utilize this food in the production of caloric 
energy, as above stated. With this we must consider that the utili- 
zation by the infant of cows' milk is not perfect, for we have the 
following differences between the breast- and bottle-fed infant, which 
are apparent on the surface. The increase of weight is irregular in 
the bottle-fed infant as compared to the regular increase in the 
breast-fed infant. The daily fluctuations of temperature in the 
bottle-fed infant are irregular as compared to the fluctuations in the 
breast-fed infant. The bottle-fed infant, as a rule, is an anaemic 
child ; the breast-fed infant the contrary. The bottle-fed infant 



HUMAN-BREAST MILK. 79 

is rachitic even from birth. It is more susceptible to infection, less 
resistant to the inroads of disease. It is deprived, notwithstanding 
its utilization of the calories in cows' milk, of the enzymes and 
alexins present in the human milk. Therefore the metabolic proc- 
cesses in the infant fed upon the bottle and those on the breast must 
necessarily dlifer, and in this respect our scientific data are still 
incomplete. We cannot replace human milk completely by any 
form of animal milk known. 

III. THE FOOD OF THE INFANT. 

In considering the subject of infant- feeding we distinguish between 
the infants fed at the breast by the natural method and those fed 
with some substitute for the breast, such as cows' milk or infant 
foods, or dilutions of the same. 

In considering the subject of infant-feeding we will study the 
food itself, and take up first in order the breast milk. 

Human-breast Milk. 

Colostrum. — From the third or fourth month of pregnancy the 
human breast begins to show signs of functionating and secretes a 
yellowish-white, thick, sticky substance called colostrum. As the 
period of pregnancy approaches the seventh month the secretion 
of colostrum becomes more active, and its physical properties are 
those of a thin, grayish-yellow fluid which exudes from the breast- 
nipple under slight pressure. 

Physical Properties. — Colostrum differs from the normal milk 
secretion in being of a light-yellowish or grayish-yellow color. It 
is markedly alkaline in reaction. It is rich in fats and proteids, 
poor in casein, in that the albumin exists in relatively greater quan- 
tity. The composition of colostrum varies from time to time until 
the period approaches when it is replaced gradually by the normal 
milk secretion. This occurs about twelve days after birth in a nor- 
mally functionating breast. At this time colostrum, as such, should 
have disappeared. 

The average composition of colostrum, according to Camerer and 
Soldner, is as follows : 

Water 86.70 

Proteids 3.07 

Fat 3.34 

Milk sugar 5.27 

Ash ^ . . 0.40 

It has a specific gravity of 1.040 to 1.060. Microscopically colos- 
trum, in addition to fat-globules, leucocytes, pavement epithelium, 
granules of casein and phosphates, contains the so-called colostrum 
corpuscle and the crescent-shaped bodies of Lourie. The fat- 
globules have similar physical properties to the fat-globules of the 



80 



THE FOOD OF THE INFANT. 



milk, and, as in human milk, they are found associated with the 
cresent-shaped bodies of Lourie, to be described (Fig. 12). 

The colostrum corpuscle is a spherical body four or five times 
larger than the milk-globule, and measuring 13// to 40/i in diameter. 
It contains fat in the granular and globular state. The colostrum 
corpuscle is looked upon as a degenerated leucocyte by some 
(Czerny). The coloring-matter of colostrum is contained in the 
colostrum corpuscle. These colostrum corpuscles are the distin- 
guishing feature of colostrum as compared to milk, and so long as 
they are present in the milk to any appreciable extent the milk 
cannot be considered as fit, in every sense, for continued infant- 
feeding. If lactation, for one reason or another, is interrupted, the 
colostrum corpuscles reappear in the milk. When lactation is again 
established these corpuscles disappear from the secretion. Should 

Fig. 12. 




Colostrum corpuscles and crescents of Louri6. (Marfan.) 

colostrum persist for too long a period in the breast, the infant, as a 
rule, does not thrive. It can thus be seen that from the twelfth 
day or thereabout after delivery of the infant, the milk which takes 
the place of the so-called colostrum must contain either no corpus- 
cles at all or in a vanishing quantity. 

In addition to the colostrum corpuscle, colostrum contains an 
interesting cresent-shaped body, described in connection with human 
milk, which is seen adherent to the external border of the fat- 
globule. Some of these colostrum crescents may present an inti- 
mation of a nucleus. They have been described by Lourie, and can 
be seen by extracting the fat from the colostrum and staining with 
methylene blue or thionine. 

Milk. — Milk may appear in the breasts the fifth, sixth or tenth 
day after delivery. In exceptional cases I have seen the milk 



HUMAN-BREAST MILK. 81 

delayed as late as the third week ; or it may diminish after having 
appeared and then increase after a few weeks. 

There are very many important facts concerning the chemistry 
of human milk, a knowledge of which is still lacking. Older 
analyses of human-breast milk give the gross amount of proteids, 
and Hoppe-Seyler suggested that the casein of human milk, or for 
that matter cows^ milk, should be determined aside from the total 
quantity of proteids. Therefore the older analyses which deal with 
the total amount of proteids under the heading of casein are not as 
useful to us to-day as the more modern analyses which distinguish 
between the casein and other proteids in the milk. The great 
importance of this point will become more apparent when we study 
the composition of cows' milk and attempt to modify it to conform 
to the composition of human milk. 

Composition. — The composition of breast milk varies not only in 
different women at various periods of lactation, but in the same women 
at different times of the day. The result is that various analyses differ 
with each other in a sense, but at the same time agree within certain 
limits. The student can appreciate these discrepancies by studying 
analyses of milk given by a number of authors. Whereas there are 
differences in proteids ; these differences have certain limits and with 
these we should be well acquainted. 

Konig's analysis, as modified by White and Ladd. gives the fol- 
lowing composition of human milk and cows' milk : 

Cow. Human. 

Caseinogen 2.88 0.59 

Whey proteids 0^ 1^ 

3.41 1.84 

The casein in cows' milk comprises five-sixths of the proteids ; 
in human milk, two-sixths of the total amount. We should bear 
this important fact in mind in reading the following tables compiled 
from Camerer and Soldner, showing the composition of human milk : 

Colostrum 5.0 4.5 3.5 

Milk, fifth day 2.3 6.7 1.6 

Milk, ninth day 3.4 6.7 1.4 

Milk, first month 2.6 7.3 1.1 

Second and third months 2.4 to 1.9 7.5 0.9 

Backhaus gives the following table of average composition (in 
100 parts) of human milk : 

Water 88.20 

Proteids / ^'"^^ casein. 

■'•'■•' \ 1.00 albumin (whey proteids). 

Fat 3.50 

Sugar 6.20 

Ash ... 0.25 

6 



82 THE FOOD OF THE INFANT. 

On comparing these figures with those of K5nig, White, and 
Ladd, it will be seen that White and Ladd include all the proteids 
exclusive of casein under the name of whey proteids. The whey 
proteids are principally lactalbumin and lactoglobulin. 

The above analyses tend to show that one examination of any 
breast milk will give no definite information as to its constant quali- 
ties ; it will only tell us the composition of that one specimen of 
milk. In a general way we can speak of averages, and these we 
shall try to elucidate under the various headings. In order to appre- 
ciate the wide variations in the percentages of the proteids, sugar, 
and fats present at the different periods of lactation, it is further 
necessary to study the following analyses of leading authorities : 

Proteids. Sugar. Fat. 

Pfeiffer 1.049-8.04 4.20- 7.60 0.70-9.00 

Johanessen and Wang . . 0.900-1.30 5.90- 7.80 2.70-4.60 

V. and J. Adiiance .... 0.230-2.60 5.35- 7.95 1.31-7.61 

Schlossmann 0.560-3.40 5.20-10.90 1.60-9.46 

Compared with human milk, the following table of animal milk 
is instructive (Konig) ; 

Human. Cow. Goat. Ass. 

Water 89.6 87.7 87.3 89.6 

Casein 1.4 3.0 3.0 0.7 

Albumin 0.6 0.4 0.5 1.6 

Fat 3.1 3.7 3.9 1.6 

Sugar 5.0 4.5 4.4 6.0 

Ash 0.3 0.7 0.8 0.5 

Proteids. — There are four albuminous bodies or proteids in human 
milk. The most important is the casein, which is in a class by 
itself. The other group of proteid bodies includes the soluble albu- 
mins or whey proteids (lactalbumin), globulin, and opalisin. The 
casein of human milk comprises two-sixths of the total amount of 
proteids ; whereas in cows' milk it comprises five-sixths of the pro- 
teids. This is an exceedingly important distinction between the two 
milks. The casein is, according to reaction, a different casein from 
that of the milk of lower animals. Szontagh and Wrobelewski 
contend that whereas the casein of human milk does not yield 
pseudonuclein on pepsin digestion, it is not a nucleo-albumin, and 
hence differs widely from the casein of cows' milk. Human milk, 
as stated, is not only poorer in casein than cows' milk, but the casein 
is less in proportionate combination with the remaining proteids and 
lactalbumin. This in part explains the more flocculent nature of 
the casein coagulum in human milk. 

The casein of human milk is derived from the protoplasm of 
the cells of the mammary gland. It is set free from the cells of 
the mammary gland in which the fat is formed. In addition human 



PLATE III, 



FIG. 2. 




FIG. 3. 



FIG. 4, 




Microscopic Appearances of ^A^oman's Milk. 

Fig. 1.— Normal milk, showing the preponderance of mediu.m-sized fat-globu.les. 
Fig. 2 —Poor milk. Preponderance of large fat-globules and a paucity of fat. 
Fig. 3.— Poor milk, a paucity of fat and an almost granular state of the fat- 
globules. 
Fig 4. — Colostrunn of later pregnancy. 

Figs. 1, 2 and 3 from Fleischman. Fig. 4 from Marfan. 



HUMAN-BREAST MILK, ■ 83 

milk, in the proteids, contains lecithin, 0.58 per cent. (Burrow) ; 
iron, 3.52 to 7.21 mg. to the litre (Jolles and Friedjung). 

Fats. — The fat of human milk is contained in the so-called fat- 
globules. On placing a drop of human milk under the microscope, 
the fat-globule is seen as a highly refracting, spherical body. The 
globule varies in measurement from 0.001 mm. to 0.02 mm. in 
diameter (Plate III.), as compared to 0.0016 to 0.01 mm. the size 
of the fat-globule of cows' milk. It is therefore larger than that 
of cows' milk. The fat of human milk is a yellowish-white mass, 
when separated resembling butter, with the specific gravity of 0.966. 
It melts at 34° C, and is solid at 20.2° C It contains butyric, 
caproic, capric, myristic, palmitic, stearic, and oleic acids. It is 
poor in volatile fatty acids. The non- volatile fatty acids consist of 
fully 50 per cent, oleic acid, while the palmitic and myristic acids 
exist in greater quantity than the stearic acid. 

In addition to the casein and fat we have the water, 89.6 per 
cent. Moreover, human milk contains nucleon, 0.124 per cent. ; 
lecithin, 0.58 per cent. ; iron, 3.52 to 7.21 mg. to the litre. 

If milk is stained with carbol thionine or methylene blue there 
are seen, as in the colostrum, crescent-shaped bodies which are adher- 
ent to the outer border of the fat-globule. They are not nucleolar 
or remains of nuclei, but are portions of the mammary epithelium 
which have adhered to the milk-globule at the time of its expulsion 
from the cell (Louri^). 

Mineral Salts in the Milk. — Human milk contains a number 
of salts, among which are calcium phosphates, potassium, magne- 
sium, iron, alum, calcium and sodium chlorides, sodium carbon- 
ate, traces of flourine and silicium. The most important of these 
salts are the tribasic calcium phosphates, part of which are held in 
solution, another part exists in a colloid state, the remaining portion 
being in suspension, and is seen under the microscope as minute 
dust-like particles in the milk, -^-oVo ^^"^- ^^^ diameter (Duclaux). 
The tribasic calcium phosphate is insoluble in water, but in the 
milk is held in solution by the presence of the alkaline citrates. 

Salts in the milk. Human milk. Cows' milk (Soldner). 

Natrium chloride 1.35 0.962 

Calcium chloride 0.70 0.870 

Calcium phosphate 2.50 1.477 

Natrium phosphate 0.40 

Magnesium phosphate 0.50 0.336 

Carbonate of soda 

Fluorite calcium trace. 

Potassium citrate 0.495 

Magnesium citrate 0.367 

Calcium citrate 2.133 

Iron phosphate 0.01 

Reaction. — The reaction of human milk depends on the presence 
of the contained salts. It is alkaline to litmus and acid to phenol- 



84 THE FOOD OF THE INFANT. 

phthalin. The actual quantity of sodium and potassium varies, the 
sodium being more abundant than the potassium at the beginning 
of lactation (De Lange). In other words, the reaction of human 
milk is amphoteric. 

Specific Gravity. — The specific gravity ranges from 1.028 to 
1.034, being lower in poorly nourished women. 

Bacteria in the Breast Milk. — A woman in good health will 
show bacteria in her milk. The bacteria are found in the galactif- 
erous ducts of the breast nipple. On the expression of the first 
few drops of milk, therefore, and the washing out of these ducts, it 
will be found that the after-coming milk is sterile. These bacteria 
belong principally to the Staphylococcus albus class. The Staphy- 
lococcus pyogenes aureus and some few streptococci have been found 
by Kohn and Neuman. These bacteria have no ill-effect on the 
infant, and the attempt to trace dyspeptic disturbances to them has 
been rather far-fetched. 

Enzymes and Alexins of Human Milk. — According to the 
latest investigations, human milk contains certain derivatives of the 
living cell, which exist in the proteid elements of the milk. Not 
much is known about them as yet, but their presence proves beyond 
a doubt that human milk is a substance essentially different from 
the milk of other animals. Moreover, their presence in the milk 
and the presence of other substances in animal milk distinguish 
milk as a living product and not a dead substance. 

The enzymes are the soluble ferments in human milk, the most 
important of which is the so-called amylase, first described by 
Bechamp and subsequently by Moro. It is capable of converting 
starch into sugar in the same manner as does the secretion of the 
parotid gland ; in other words, it exerts a diastatic action on starch. 
Amylase is not found either in cows' or sheep's milk. It is 
destroyed by heat, and human milk heated above a certain tempera- 
ture loses its amylolytic properties. This ferment is present, though 
to a much less degree, in dogs' and asses' milk. It is supposed to 
be derived from and is a product of the glandular tissue of the 
mammary gland, and is not primarily present in the blood. The 
reason of its presence in human milk is not quite understood, inas- 
much as the infant reared exclusively on breast milk does not 
receive any starchy substances with its food. 

Marfan isolated another ferment in the milk, called lipase, which 
is capable of splitting monobutyrin into butyric acid and glycerin. 
This lipase is present to a slight extent in cows' milk. Human 
milk contains also a ferment capable of splitting salol into phenol 
and salicylic acid, and a substance capable of coagulating fibrin, 
inasmuch as a minute quantity of human milk added to hydrocele 
fluid causes its immediate coagulation (Moro and Hamburger). This 
substance is not present in cows' or goats' milk, Moreover, human 



HUMAN- BREAST MILK. 85 

milk, as also the milk of animals, possesses certain vital specific 
properties. Bordet, Moro, and others have shown that if human 
milk, cows^, goats' or any other animal milk be injected into the 
peritoneal cavity of an animal, the serum of that animal in very 
high dilutions is capable of coagulating the milk of the animal 
whose milk was injected into its body. This last specific property 
of the milk of all animals proves beyond question that milk pos- 
sesses vital properties hitherto not attributed to it. 

Human milk contains so-called alexins — that is, bactericidal and 
globulicidal substances — and Moro has shown that the serum of the 
blood of the breast-fed infant is more bactericidal than the serum 
of the blood of the infant fed upon cows' milk. 

Amount of Breast Milk Consumed by the Infant in Twenty- 
four Hours. — Camerer has collated and analyzed the results obtained 
by Ahlfeld, PfeiflFer, Weigelin, and Hahner as to the quantity of 
breast milk taken daily by an infant. These figures were obtained 
by weighing an infant from the earliest period before and after nurs- 
ing the breast. Camerer gives us the following table, the amounts 
being indicated in cubic centimetres : 

Day. 



1st. ^ 3d^ 4th. 5th. 6th^ 7th. IQth. 14th . 
30 130 240 290 330 365 400 450 500 

Amount of Milk Taken. 

Middle 2d week. 4tli week. 7th week. 10th week. 20th week. 

Minimum. . . 210 380 520 600 700 

Medium ... 440 580 770 800 900 

Maximum . . 540 810 1040 1170 1150 

The amount of breast milk consumed by the infant at each nurs- 
ing must vary with the frequency with' which the infant is placed at 
the breast. If the infant is placed at the breast five times in twenty- 
f)ur hours the mean quantity of milk taken at each feeding is 
quite large as is seen by consulting Ahlfeld -s figures. Thus an 
infant at the breast 

1 month old consumes 104 c.cm. 



2 months 

3 

4 

5 

6 

7 



163 
173 
212 
212 
214 
217 



These figures are within the limits of stomach capacities given 
by Pfaundler and in excess of those of Fleischman, Holt, and Eotch. 
If the infant nurses at more frequent intervals than Ahlfeld's baby, 
the quantity of milk ingested at each nursing will be less than the 
above figures. 



86 THE FOOD OF THE INFANT. 

It is noteworthy that on the first day of life the infant observed 
by Camerer nursed three times, and seven times in twenty-four 
hours from the second to the fourteenth day. Each nursing occupied 
a mean of about twenty to twenty-five minutes. These data are of 
value in the artificial feeding of infants. 

Czerny shows that, as regards the quantity of breast milk 
secreted, there are, first, those cases in which the breast milk 
increases in quantity up to the ninth week and then remains sta- 
tionary in amount up to the period of weaning ; secondly, those 
breasts in which the amount of milk secreted daily increases from 
the earliest period steadily to the period of weaning, when the 
amount secreted is at its highest. 

Changes in the Composition of Milk. — Daily Changes. — Milk 
may vary ia composition in the course of twenty-four hours in the 
same nurse, both in the total amount of proteids and fats, to the 
extent of 1 per cent, or more. Schlichter has found that the 
changes occur at various times in the day. 

The composition of the milk of the nursing woman at different 
hours of the day may be seen in the following table by Schlichter : 

Nurse A. Casein. Fat. Proteids. Sugar. 

Morning 1.10 0.80 1.69 7.11 

Noon 1.10 1.88 2.16 6.92 

Night 3.16 1.95 6.83 

Nurse B. 

Morning 0.55 3.77 1.19 5.37 

Noon 0.77 3.90 1.91 6.15 

Night 0.71 3.73 1.26 6.19 

Nurse C. 

Morning 0.55 3.61 0.19 6.18 

Noon 0.83 4.21 1.08 6.24 

Night 0.41 3.60 1.16 6.47 

Gregor has shown that the variation in the color and consistence 
of the stools of infants can be accounted for by the variation in the 
gross amount of fats in human milk at different times of the day 
and from day to day. 

Influence of Foods on Breast Milk. — A diet rich in nitrog- 
enous substances increases the quantity of the milk and the percent- 
age of fats and proteids. A diet rich in fat may increase the percent- 
age of fat in the milk. On the other hand, it is not always possible 
to increase the casein in the milk by means of diet if the milk is poor 
in this constituent (Konig). Starvation lessens the quantity of the 
milk and the proportion of the casein to the other proteid bodies in 
the milk in the same manner as does a poor dietary (Decaisne). If 
we enlarge the diet we improve the milk. Beer and malt liquors 
increase the quantity of the milk and the percentage of its fat-con- 
stituents (Konig). 

In trying to improve the milk of the human breast we should 



HUMAN-BREAST MILK. 87 

not resort to too much experimentation, for a good milk will some- 
times be made unfit for the infant by placing the nurse or the 
mother on a diet to which she is unaccustomed. On the other hand, 
I have seen the milk retain its colostrum characteristics through the 
fact that the mother did not follow out the dietary to which she was 
accustomed previous to delivery and did not take her usual exer- 
cise. Women accustomed to a wholesome, moderate dietary will, 
if fed liberally with fats and carbohydrates, secrete a milk rich in 
fats and poor in proteids ; such a milk will at once disagree with 
the infant (Konig). If a nurse has been on an insufficient diet, the 
diet should be increased in a general way. She should have a mod- 
erate allowance of meat, partake sparingly or not at all of tea, 
coifee or beer, and have sufficient exercise. If with these changed 
conditions the milk does not improve both in quantity or quality we 
should not hesitate to replace the nurse by another ; or if the mother 
is nursing the infant, to aid the breast with artificial food. This 
is preferable if the mother is nursing to taking the infant away 
from the breast. 

Drugs and Foreign Substances in the Milk. — Iodine and 
salicylic acid may pass from the blood into the milk of the human 
breast. Iodine may even cause iodism in the nursing infant when 
the nurse is taking any appreciable amount of iodide of potassium 
(Koplik). Iodine is eliminated in combination with the casein of 
the milk. As to the appearance of other substances, such as drugs, 
in the human milk if taken in medicinal doses by the mother or 
nurse much is to be learned, for very little is actually known. 
Opium is not eliminated if taken in ordinary doses, though atropine 
may, if taken by the nurse, be eliminated in the milk and cause 
dilatation of the pupil in the infant. Alcohol taken in limited 
amounts, as is customary at the table, is not found as alcohol in 
breast milk ; but if large quantities are taken, from two-tenths to 
six-tenths of 1 per cent, of alcohol may be found in the milk. 

Passage of Bacteria of the Infectious Diseases Into the 
Breast Milk. — The extent to which bacteria of the various diseases 
may pass into the milk of the infected woman is still a matter of 
question. Under the heading, Contra-indications Against Nursing 
the Infant, this matter has been discussed in part. It has been 
proved that the toxins, antitoxins, and agglutinins of the infectious 
diseases, such as typhoid fever and diphtheria, may pass into the milk 
of the nursing woman suffering from these diseases. The bacillary 
infection of the milk, however, is quite a different matter, concern- 
ing which much is to be learned. In local tuberculous infection of 
the mammse it can well be understood that bacilli may gain direct 
access to the milk through infectious foci of the galactiferous ducts. 
It is still questionable whether milk from a gland free from local 
foci, though coming from a woman affected with tuberculosis, may 



88 THE FOOD OF THE INFANT. 

contain tubercle bacilli. In typhoid fever and diphtheria the 
bacilli may appear in the milk of a woman suffering from severe 
systemic invasion of the bacilli of either of these diseases, but, as a 
rule, this is not the case. In pneumonia we can scarcely apply to 
the human subject the reuslts obtained in the lower animals, for in 
the former the disease is rarely an invasion of the blood to the 
extent seen in the lower animals. Thus, cases such as those pub- 
lished by Bozzolo, in which pneumococci were found in the milk of 
a woman suffering from severe pneumonia and endocarditis, are 
exceptional. 

Toxins, Antitoxins, and Agglutinins. — Tetanus toxins and 
antitoxins may pass into breast milk, and in certain animals, such as 
mice, this milk may confer immunity on the nursling (Ehrlich, 
Brieger). 

Diphtheria toxin and antitoxin may be eliminated in the breast 
milk. Ehrlich and Wassermann found that goats immunized 
against diphtheria could confer this immunity through the milk. 
Roux and Martin confirmed this observation in the cow. It has 
also been proved that the breast milk of women convalescent from 
typhoid fever possessed agglutinating properties on the Eberth 
bacillus similar to that of the blood (Achard, Bensaude), and that 
this agglutinating property could be transferred to the blood of the 
infant nursing this milk (Landouzy, Griffon, and Casteigne). In 
passing from the blood into the breast milk the agglutinating sub- 
stance is much weakened, likewise more so when transferred from 
the milk to the blood of the nursing infant. 

The above facts would seem to indicate that the question as to 
whether the breast milk of a mother or nurse suffering from any 
disease is fit for the nursling is not an indifferent one. The pas- 
sage of toxins, antitoxins, and agglutinins into the milk should, 
with reservations mentioned elsewhere, forbid the use of any breast 
milk coming from a mother or nurse the victim of active acute or 
chronic disease. 

Menstrnation. — The effect of menstruation on breast milk is 
still a matter of much discussion. Some investigators, such as 
Rotch, think they have found some variations at this period, not 
only in the percentage of the fat, but in the proteids, from that 
which existed before menstruation. Other authors think the great- 
est variations will be found in the fats (Bendix). I am inclined, 
however, from my own experience to believe that variations in breast 
milk during menstruation are exceptional, for the great majority of 
infants do not show at this time any disturbances of the functions 
of the gut. An exception to this may probably be the first men- 
struation of lactation. Infants at this time may have green move- 
ments and slight colicky pains which persist until menstruation is 
established in the mother, when all functional disturbances of the 



METHODS OF ANALYSIS OF HUMAN MILK. 89 

gut disappear and the children do not seem to be disturbed by 
the recurrence of the function. In fact, if we study the tables of 
the analyses made before and during menstruation and subse- 
quent to this period we shall see that the variations are no greater 
than those which occur from day to day when menstruation is absent. 
Pregnancy. — The question is frequently asked, " Has pregnancy 
any effect on the quality or quantity of the milk, and may an infant 
nurse the breast of a pregnant woman ? " Having conducted a 
very large dispensary class in diseases of infancy and childhood for 
fifteen years, I not infrequently saw infants nursed at the breast of 
pregnant mothers. Such infants did not seem to suffer ; some of 
them, in fact, being beautiful babies. Examination of these mothers 
showed them to be pregnant from four to six months. The milk 
secretion was not markedly changed in amount. This corresponds 
to what has been established by Poirier, who found that of 100 
pregnant mothers who nursed their infants, 72 infants showed no 
change in their general well-being, while 20 showed disturbances 
necessitating immediate weaning. Eight infants showed slight intes- 
tinal disturbances. The question may be justly asked whether a 
like proportion of cases might not be met with necessitating wean- 
ing among mothers not pregnant and nursing their babies. Preg- 
nancy may diminish the amount of milk, but in the majority of 
cases no change occurs. It is just, however, unless extraordinary 
indications to the contrary exist, that a mother should not be asked 
to nurse her baby while pregnant with another. Such an infant 
should be weaned from the breast. 



Methods of Analysis of Human Milk. 

In the section treating of the examination of breast milk it 
was shown that with experience it is possible to decide in a gen- 
eral way as to the quality of the milk without chemical analysis. 
Emergencies, however, arise which may necessitate more careful 
examination of the milk in order to account for some disturbing 
symptom in the infant. After thriving for a few weeks the infant 
may, without apparent cause, cease to gain in weight, or the move- 
ments may be abnormal, or there may be colic. Under these con- 
ditions it is certainly an advantage to be able to determine the com- 
position of the milk, since a chemist is not always at hand. Conrad, 
a physician in Bern, has devised some instruments which are easily 
manipulated and are within the reach of every physician. His 
article, published in 1880, is still unsurpassed in clearness of detail. 
The milk to be used in all analyses is that obtained in the mid-period 
of nursing. 

Specific Gravity. — To ascertain the specific gravity, Conrad 
reduced the size of Quevenne's lactodensimeter so that it could 



90 



THE FOOD OF THE INFANT. 



Fig. 13. 



Ill 



Fig. 14. 



Conrad's lactobutyr- 
ometer. 



Conrad's lactoden- 
simeter. 



be utilized for taking the specific 
gravity of small quantities of 
mother's milk (Fig. 14). The 
specific gravity is taken at 15° C. 
The scale runs from 1020 to 
1050. 

Fat. — Conrad estimated the 
fat by first calculating the cream 
layer. This he determined by 
means of a graduated glass cylin- 
der devised by Bouchardat, Que- 
venne, and Chevalier. This cylin- 
der he reduced in size. The 
method is so unreliable that it is 
merely mentioned in passing. 

Of greater reliability is the 
Marchand tube, reduced in size 
by Conrad. The set consists of 
two of these tubes. Each tube 
analyzes 5 c.c. of milk (Fig. 
13). _ 

Five c.c. of milk are poured 
into the tube, and then 5 c.c of 
ether. These are well shaken 
after a drop of officinal caustic 
soda solution has been added. 
Absolute alcohol is then added 
up to the A mark. The whole is 
again shaken and placed in water 
at 35° to 40° C. for ten or fifteen 
minutes. The fat separates above, 
and is read off. A percentage 
table accompanies the instrument. 
This instrument is not accurate. 
There is a variation of from 0.2 
to 0.5 per cent, or more. Two 
analyses are made at the same 
time for the sake of accuracy ; 
hence the two tubes. 

Lewi's Method. — More accu- 
rate than Conrad's is the method 
worked out in my clinic by Lewi. 
This is really an adaptation to 
breast milk of the Babcock sul- 
phuric acid method, as modified 
by Leffman and Beam. 



METHODS OF ANALYSIS OF HUMAN MILK. 



91 



The apparatus needed comprises a reduced Babcock Fig. 17. 
bottle, a pipette for measuring the milk and acid, and a 
smaller 1 c.c. pipette accurately divided into cubic milli- 
metres (see Figs. 15, 16, 17). 

Method. — Fill the pipette to the meniscus (this repre- 
sents 2.92 c.c. of mother's milk) and introduce this care- 
fully into the body of the 



bottle, so that the long thin 
pipette comes down into the 
body of the bottle. The 
pipette is cleansed, and re- 
filled to the meniscus with 
chemically pure sulphuric 
acid ; the pipette is introduced 
as before. This precaution 
is taken in inserting the pi- 
pette so that at this stage no 
ebullition shall occur in the 
neck of the bottle, and so 
invalidate the result. Next, 
fill the 1 c.c. pipette up to 
the sixth marking with a 
mixture of equal parts of 
fusil oil and concentrated 
hydrochloric acid ; add this 
to the milk and sulphuric 
acid and fill the bottle with 
equal parts of sulphuric acid 
and water. The bottle is 
placed in an aluminum re- 
ceiver and adjusted to the 
centrifuge. The specimens 
are revolved one and a half 
to two minutes, and the 
reading is then taken. With 
the new high-gear machine 
of Richards & Co. fifteen 
revolutions of the handle per 
minute suffice, each turn of 
the handle corresponding to 
one hundred and thirty revo- 
lutions of the bottle. 

This method, if care- 
fully carrried out, gives very 
little error, and is practi- 
cally equal to the Soxhlet 



Fig. 15. 



Fig. 16. 

r 



^4 



=^0 



/ 



/ 



\i 



Instruments employed in the estimation of fat in 
milk. Lewi's method. 



92 



THE FOOD OF THE INFANT. 



quantitative fat estimation. It can be applied to cows' as well as 
to human milk. 

The following table shows the error in the various methods as 
compared with accurate chemical determination : 





Soxhlet 
(chemical). 


Reduced 
centrifuge. 


Marchand. 


Feser. 


Specimen 


I 


4.4 per cent. 


4.4 per cent. 


3.48 per cent. 


5.00 per cent. 


<( 


11. . . . 


2.4 


2.3 " 


2.56 


2.37 " 




III. . . 


1.1 


1.1 


1.44 


1.25 *' 




IV. . . 


3.9 


3,8 


3.17 


3.25 '' 




VI. . . 


4.6 


4.7 


2.35 


3.80 




VII. . . 


2.3 


2.3 " 


3.99 


2.20 " 




VII. . . 


4.4 


4.2 


3.68 


4.20 




VIII. . 


4.7 


4.6 




3.60 



The Proteids. — To possess clinical value in the determination 
of the proteids, a method must differentiate between the amount of 
casein and that of the other proteids, such as lactalbumin and lacto- 
globulin. This is possible only by careful and exhaustive quanti- 



FiG. 18. 




Milk burette of Woodward. 

tative chemical analyses. The methods at our disposal which are 
practicable in the physician's office determine only the gross proteids. 
The gross proteids may be normal in amount, and the casein or 
caseinogen be deficient. Such milk would not be nutritious. This 
was demonstrated years ago in sick and starving women (Decaisne). 
The following is the method of Woodward for determining the 
total proteids: Two ^^milk burettes" (Fig. 18), each containing 
5 c.c. of milk, are allowed to stand overnight in a warm place 
(100° F., 38° C). They are then cooled. The milk is drawn off 
into two Esbach's tubes, and 10 c.c. of the Esbach solution added. 
The tubes are then shaken, put into a centrifuge, and rotated until 
the reading is constant. This method was perfected in the Pepper 
Laboratory, Philadelphia. The author has utilized this method, 
and found it satisfactory. 



COWS' MILK. 93 

Cows' Milk. 

Composition. — Of 700 analyses, Konig gives the following as 
the average composition of cows' milk for 100 parts : Water, 87.2 ; 
casein, 2.88 ; albumin (lactalbumin), 0.51 ; fat, 3.68 ; sugar, 4.90. 
Cows' milk has a specific gravity of from 1.028 to 1.034. It is 
amphoteric in reaction, but is relatively more acid than human milk. 
Fresh cows' milk does not coagulate on boiling, but heat causes a skin 
of casein and lime salts to form on the surface of the milk. If 
allowed to stand at the temperature of the room, lactic acid is formed 
in cows' milk as a result of bacterial growth and splitting of the milk 
sugar and coagulation or curdling of the casein occurs when the 
milk is heated ; after a while, an excess of acid being formed, spon- 
taneous separation of the casein will occur. 

Fat. — Fat is contained in cows' milk, as in human milk, in the 
form of fat-globules, which are held in suspension in the serous part 
of the milk by an envelope of albumin. There is no doubt that the 
milk-globules contain all the fat of the milk. The fat-globules are 
smaller than those of human milk. It is uncertain whether the fat- 
globules contain any protein substances. 

Proteids. — Casein. — The casein of cows' milk is a nucleo-albumin, 
contains phosphorus and coagulates when heated, as also by the 
addition of acids and rennet. The amount of casein in cows' milk 
is not only relatively but absolutely greater than in human milk ; and 
in describing human milk it was stated that the casein forms five- 
sixths of the total proteids in the cows' milk ; w^hereas in human 
milk the casein forms two-sixths of the total proteids. This one 
fact is of far-reaching importance. Simple dilutions of cows' milk 
still leave it with a greater proportion of casein, as compared to the 
other proteids in the milk, than that which exists in human milk. 
Though we may dilute cows' milk so as to reduce the proteids to the 
relative proportion in which they exist in human milk, we cannot do 
this without at the same time reducing its nutritive value ; that is, 
we fail to get the quantity of digestible proteids in the milk, although 
the proteids may exist in the same proportion in our mixture. In 
other words, the proteids of the cows' milk are not so completely 
assimilated by the infant as are those of human milk. Again, the 
casein of cows' milk is precipitated or coagulates very early with the 
aid of acid and salts ; that of human milk quite late or not at all. 
In the human stomach, therefore, cows' milk will not take up as 
much acid of the gastric juice without coagulating as will human 
milk and the coagula occur in large masses. We can readily see in 
this another disadvantage in the use of cows' milk as an infant food. 
Human milk, on the other hand, takes up a large amount of the acid 
of the gastric juice and coagulates in very fine flocculi. This finer 
mode of coagulation accounts partly for the more complete assimila- 



94 THE FOOD OF THE INFANT. 

tion of human milk by the infant. It was formerly thought that 
the casein of human and cows' milk were chemically identical. Later 
study, however, shows that the casein of human milk, in contradis- 
tinction to that of cows' milk, is not a nucleo-albumin (Szontagh). 
Human milk is richer in nucleon and lecithin than cows' milk and 
contains more combined phosphorus than cows' milk in the nucleon. 
It can be seen from this that the contention of Hoppe-Seyler, Ham- 
marsten, and Wrobelewski, that the two caseins are essentially 
different, is well founded. Not only is the casein of cows' milk a 
substance sui generis, but its digestion in the intestine of the infant 
is accomplished with great loss. Paracasein and pseudo-nuclein of 
cows' milk pass through the gut unabsorbed (Knoepfelmacher). The 
loss in phosphorus to the infant is sixteen times as great when fed 
with cows' milk as it is when fed with woman's milk. Moreover, it 
has been shown that the salts of cows' milk, especially those of lime 
and potassium, are not well assimilated by the infant gut, fully 34 
per cent, of these salts being excreted by the gut; whereas only 10 
per cent, of these salts are found in the feces of the infant fed at the 
breast. These facts are of great importance in comparing the two 
modes of feeding infants — that of the breast and the bottle. The 
prevalence of bone disturbances of the severer type in artificially fed 
infants is thus partly explained, not only by the lack of absorption 
of an important food element, the phosphorus, but also by the loss 
of the salts of lime and potassium, these being important to bone 
nutrition and growth. The increase of weight in artificially fed in- 
fants also gives us an insight into the physiological processes in such 
infants. The quantity of milk, as before stated, necessary to maintain 
nutrition is greater in the case of the bottle-fed infiint than in that 
fed on the breast. There is always a danger of overfeeding an infant 
which is bottle-fed. The increase of weight is not as regular in the 
bottle-fed infant as it is in the breast-fed infant. 

The following will show at a glance the differences in the assimila- 
tion of the various elements of cows' milk as compared to human 
milk by the infant gut (UfPelmann) : 

Cows' Milk Human Milk. 

Proteids 98.7 per cent. 99.5 per cent. 

Fats 93.5 " 97.5 " 

Salts 66.2 " 90.0 " 

Sugar 100.0 '* 100.0 " 

Ash 92.0 " 97.0 '' 

According to Forster, an infant four months of age taking 1215 
c.c. of cows' milk excreted three-fourths of the lime salts in the 
feces. 

Bacteria in Cows' Milk. — Pasteurization; Sterilization. — By 
insisting on strict cleanliness of the cows' udder, the hands of the 
milkman, and the utensil in which the milk is collected, it is pos- 



cows' MILK. 95 

sible to obtain a milk tolerably free from bacteria. In commerce, 
however, this is manifestly impracticable. Milk collected with the 
greatest care contains bacteria, and if these appear to the extent of 
only 9000 to the cubic centimetre at the time of milking, enough 
will have developed under favorable conditions to cause such an 
increase within twenty-four hours at an ordinary temperature as to 
bring this number up to 5,600,000 to the cubic centimetre (Miquel). 
It is therefore of little value to the practitioner to receive reports 
as to the number of bacteria to the cubic centimetre when the milk 
left the dairy. He has no assurance, unless the milk has been kept 
at a very low temperature, that these bacteria have not increased in 
number. Soxhlet has shown that in order to inhibit the growth of 
these bacteria in the milk, it must be kept at a very low tempera- 
ture, and in summer weather practically in contact with ice. 

The most important bacteria found in milk are the Bacterium 
lactisaerogenes, the Bacillus mesentericus vulgatus (the potato 
bacillus), and the Bacillus subtilis. Cows' milk may contain also 
streptococci which come from the udder of the animal, and any 
pathogenic bacteria, such as the pneumococcus, typhoid bacillus, 
diphtheria bacillus, the germs of scarlet fever, measles, or tubercu- 
losis, cows' milk being an excellent culture medium for the growth 
of germs of all infectious disease. 

The habitat of the bacteria of cows' milk is first the teat of the 
udder. The milk ducts in the teats are of considerable size and 
residual milk decomposes in them. The entrance of bacteria into 
these ducts, such as the Bacterium lactis aerogenes, the hay bacillus, 
the potato bacillus (Bacillus mesentericus vulgatus), is favored by 
the habits of the animal and uncleanliness in the stalls in which the 
animal is kept. Uncleanly utensils in which the milk is collected 
are a source of contamination. 

Infected Cows' Milk as a Cause of Epidemics. — Typhoid 
Fever. — Cows' milk is unquestionably an excellent medium for the 
growth of bacteria and is most readily infected ; thus, epidemics of 
typhoid fever have been traced to infected milk. Such milk 
becomes infected either in the dairy, where the fever may be preva- 
lent among the dairymen, or through dairy utensils which have been 
cleansed with infected water. 

Dysentery may be caused by drinking infected milk (Klein). 

Diphtheria. — The Klebs-Loffler bacillus grows quite well in 
cows' milk, which may consequently be the means of readily spread- 
ing the disease ; thus, school epidemics have been traced to infected 
milk. 

Scarlet fever has been conveyed by cows' milk infected by those 
contaminated with the disease (Kober, Freeman). 

Cholera Asiatica may be conveyed through milk diluted with 
infected water or milk handled by a cholera-infected individual. 



96 THE FOOD OF THE INFANT. 

Tuberculosis. — It is not the place here to discuss the transmission 
of tuberculosis to the human subject by means of the milk of a 
tuberculous cow. This matter is secondary to the more immediate 
question as to the prevalence of tuberculosis in the infant and child 
as a result of the ingestion of infected cows' milk. That this mode 
of acquiring tuberculosis is exceedingly rare will be acceded to by 
most observers, and published epidemics or isolated cases of tuber- 
culosis in children, caused by infected cows' milk, lack the evidences 
of absolute certainty as to etiology. 

Aside ftom tuberculosis, it is generally granted that suppurative 
disease of the udder of the cow may cause serious digestive disturb- 
ances in the infant by infecting the milk. In fact, certain forms 
of stomatitis are traced by some (Forcheimer) to such a source. 

Milk Acidity. — If milk is not cooled immediately after milk- 
ing, and kept cool, it soon shows a marked increase in acid reaction. 
This is due to the growth of the Bacterium lactis aerogenes, which 
not only turns the milk acid, but in doing so produces toxins which 
are of considerable danger when introduced into the stomach and 
gut of the nursing infant. Without entering further into details in 
this work, we may say that cows' milk intended for infant-feeding 
should be obtained from a herd of healthy animals, preferably of 
the Holstein type. Mixed milk is to be preferred to the milk from 
one cow, for the reason that any infectious element introduced into 
the milk coming from a large herd of animals is so diluted as to be 
less dangerous to the individual infant than the milk containing 
infectious matter coming in a concentrated form from one animal 
which may not be in good health. 

The milk should be carefully collected in utensils which have 
been thoroughly cleansed and sterilized with steam. The infant 
should obtain the milk as soon as possible after the milking ; cer- 
tainly within twenty-four hours. Having been modified and put 
up for the infant's use, the food should be presented to the infant in 
divided portions, each of which is sufficient for a nursing. 

In large cities, where the milk does not come direct from the 
dairy to the infant, it is still thought advisable to subject the milk 
to various forms of sterilization or heating, in order that the con- 
tained bacteria may, for the most part, be destroyed, and that it 
may remain fit for feeding the infant for fully twenty-four hours. 
In places where the milk can be obtained direct from the dairy, and 
where we are certain that the collection of the milk has been car- 
ried out ^vith care and with the especial object in view of feeding 
infants, we may do away with the heating process, especially in the 
winter time. In the summer, however, some form of sterilization 
is necessary. 

Under the term sterilization the author includes both Pasteuriza- 
tion and sterilization. 



COWS' MILK. 



97 



Pasteurization. — Pasteurization is to-day the process most in 
vogue in this country for the preservation of infant food, and also 
to destroy, for the most part, any deleterious bacteria contained in 
the milk. It was first perfected by Pasteur, and therefore bears his 
The milk is subjected, in a suitable apparatus, to a tem- 



name. 



Fig. 19. 



Fig. 20. 





Freeman Pasteurizer. 

perature of 65° C. (149° F.) for a variable length of time, gener- 
ally half an hour, and then rapidly cooled to 20° C. (68° F.) The 
most practical apparatus for this purpose was devised by Dr. Free- 
man, and is sold in the shops as the Freeman Pasteurizer. If 
properly carried out with this apparatus, the 
method destroys all pathogenic germs which Fig. 21. 

may be present in the milk, and also a 
large percentage of the other bacteria of the 
milk, including most of the Bacterium lactis 
aerogenes, but does not destroy any sporulated 
bacteria, such as the Bacillus mesentericus 
vulgatus. 

Sterilization. — Sterilization is the proc- 
ess of heating milk to 212° F., or 100° C. 
This may be done by means of the Arnold 
Steam Sterilizer (Fig. 21), or by .simply 
placing the milk in properly corked bottles 
in boiling water. As a rule, the milk is 
heated for twenty minutes, when it is con- 
sidered sterilized. The milk should then 
be rapidly cooled, as in the process of Pas- 
teurization, for by this process the fat of 
the milk will not separate. Sterilization 

is best performed by the above processes, but the ordinary steril- 
izers will not render the milk absolutely sterile. It will not 
destroy any sporulated bacteria, but will destroy the Bacterium 
7 




Arnold Steam Sterilizer. 



98 THE FOOD OF THE INFANT 

lactis aerogenes and all pathogenic germs. Milk which contains 
sporulated bacteria^ such as the potato bacillus (Bacillus mesenteri- 
cus vulgatus), may after a short time undergo a change due to the 
proliferation and action of the sporulated bacteria, which have not 
been destroyed by sterilization under ordinary atmospheric pressure. 
This consists in a splitting up of the casein and a so-called pepton- 
ization of the milk. This change begins after a few days, and 
when complete renders the milk alkaline in reaction and sweet- 
ish in taste. Milk, unless it has been sterilized under two atmos- 
pheres of pressure and at a temperature above that obtainable in 
the household sterilizer, is never completely sterile. Milk which 
has undergone the above peptonization is unfit for infant-feeding. 

Disadvantages of Sterilization as Compared with Pasteuri- 
zation. — In describing sterilization and Pasteurization of milk, it 
has been intimated that sterilization has its disadvantages, and these 
are, in short, that the lactalbumin of the milk is coagulated to a 
slight degree ; the casein is changed, so that it is not as absorbable ; 
the fats are liquefied, so that in sterilized mixtures they may be seen 
on the surface in the form of an oily layer ; and the lime salts are 
converted into unabsorbable compounds, so that infants taking ster- 
ilized milk lose these salts for the economy. They do not get the 
necessary bone pabulum. This would account in part, if true, for 
the prevalence of scurvy in infants who take sterilized milk as an 
exclusive food for too long a period of time (Cronheim and Miiller). 

Though sterilization was at first a great step in advance, 
inasmuch as the process presented to the nursing infant the possi- 
bility of obtaining its food in a wholesome condition hours after its 
preparation, even in the hottest weather, there developed certain 
disadvantages in connection with its prolonged use. It has been 
noted, partly owing to the increased use of sterilized milk and partly 
to the fact that bottle-feeding has become much more general to-day 
than formerly, that infants who take sterilized milk to a certain 
extent do not thrive as well as infants who obtain either a mixed 
diet or a food not so thoroughly cooked. The result has been a 
decided increase in the number of scurvy cases, undoubtedly due to 
the changes in infant food. Aside from the danger of scurvy, a 
certain proportion of infants who do not develop scurvy and who 
are fed exclusively on sterilized milk remain stationary in weight, 
although the stools of such infants may be perfectly normal in 
appearance. 

Again, infants who are taking sterilized milk develop in a cer- 
tain proportion of cases inordinate constipation, and this in itself 
is a very troublesome feature in the feeding of these cases. In 
looking for another method of preserving the infant food, at 
least here in America, Pasteurization was next taken up. It was 
found, however, that the heating of the lactalbumin even to a tem- 



COWS' MILK. 99 

perature of 70° C. had its disadvantages, in that a certain amount 
of lactalbumin was coagulated. Still, the disadvantages of Pas- 
teurization were less, as compared to those of sterilization, and it 
was at once apparent that if Pasteurization could be applied as a 
method of preservation of infant food, it would be a step in advance. 
The author at first advocated the heating of milk for infant-feeding 
at a lower temperature, a temperature subsequently taken up by 
Monti, of Vienna, of 180° F. At this temperature milk will keep 
twenty-four hours even in warm weather, with ordinary care, with- 
out turning sour. Even this temperature was found excessive, and 
Dr. Freeman advocated a still lower one for Pasteurization, and 
devised an instrument for carrying out this process, which to-day is 
in general use. 

Coincident with the agitation against sterilization, and even Pas- 
teurization of milk, the dairy methods have been so improved to-day 
that the time of Pasteurization can be reduced, and in midwinter, in 
large cities, the milk can be obtained in such purity as to be given raw 
to the infant. The whole question, therefore, of the preservation of 
milk has resolved itself into obtaining a milk as free from impurities 
and as recently from the dairy as possible. Thus, if we are certain 
of the cleanliness of our milk and the care with which it is handled. 
Pasteurization can be followed out as a method of preservation of 
the infant's food, even in the summer time ; but such Pasteurized 
milk, no matter how clean the original milk when received from the 
dairy, must be kept carefully on ice in order to prevent its turning 
sour. Among the poor in large cities, however. Pasteurization is not 
safe in midsummer, and where large numbers of infants are fed from 
laboratories careful sterilization offers the best safeguard against in- 
fantile summer diarrhoea. In the fall and winter, pasteurization, in 
large cities is quite sufficient to preserve the infant food ; and, as has 
been stated, in winter we may even, if we are sure of the source of 
our milk and its recency from the dairy, give raw milk to infants. 
Sterilization and Pasteurization, therefore, are simply methods of 
preservation of infant food, and have nothing intrinsic in themselves 
as regards the problems connected with infant-feeding. 

Experimental Study of the Assimilation of Sterilized j Pasteurized 

and Raio Milk. 

Nitrogen taken Nitrogen remaining 

in milk. in feces. 

Grammes. Per cent. 
First infant — 

Pasteurized milk 10.9209 4.6 

Sterilized milk 13.7449 4.9 

Kawmilk 5.3914 3.4 

Second infant — 

Boiled milk 32.643 4.5 

Sterilized milk 30.969 4.3 



100 THE FOOD OF THE INFANT 

The table given above shows the comparative digestibility of raw, 
Pasteurized, and sterilized milk (Koplik), as indicated by the per- 
centage of nitrogen remaining in the fseces of the infant. These ex- 
periments were performed by feeding the same infant with raw and 
heated milk. The results showed that, although the differences are 
slight, they are in favor of milk subjected to little or no heat. Doane 
and Price have confirmed these results by experiments on the calf. 

What Shall the Practitioner do in Regard to Sterilization 
and Pasteurization ? — If the patient has access to a milk which is 
only twelve hours from the dairy we may simply Pasteurize this milk 
both summer and winter, and in the summer-time it should be care- 
fully kept on ice. During the winter we may give such a milk 
raw if obtained from a mixed herd of cattle. Raw milk from a 
limited herd is dangerous, inasmuch as the dilution is not great 
enough to eliminate impurities from sick cows, should there be such, 
in a small herd. The practitioner should therefore advocate a mixed 
milk from a large herd as the best safeguard against infection of the 
infant. The dairy should be kept scrupulously clean, as should also 
the animals, and the milk kept in clean utensils, in order that the 
above ideas may prove beneficial to infants. If the infant's milk 
(modified) is to be carried any distance during the summer, steriliza- 
tion is a safeguard for a short period of time. 

Raw Milk in Infant-Feeding. 

With the improved methods of dairy hygiene and care exercised 
in most cities in the collection of milk intended for infimt-feeding, 
the milk contains less bacteria and reaches the infant much earlier 
to-day than formerly. The result of this, at least in New York, 
where it is possible to obtain milk within twelve to twenty-four hours 
of the milking-time, has been that the milk is of a very low acidity 
and bacterial content. The question arises whether we may not 
give such milk, modified properly, in a raw state to the infant. For 
even Pasteurization, it must be admitted, tends to change the 
ingredients of the milk to such an extent as to compromise their 
nutritive value. 

The author in practice Pasteurizes the infant's milk in the winter- 
time, and in many cases gives the milk in the raw state. In the sum- 
mer, however, in large cities, where the icing of milk may have been 
imperfect, it is safest to sterilize the milk during the heated term. 
This is only for a period, at most, of three months. An infant 
taking sterilized milk under proper conditions during the heated term 
is not injured by such a food, and is protected from an attack of 
gastro-enteritis, for it is not possible, even though great care be ex- 
ercised, to prevent an occasional bottle of milk from increasing in 
acidity. The result of such a change might be an attack of diarrhoea 



NUBSING BOTTLE. 101 

which would endanger life. In the fall, winter, and early spring the 
practitioner, if he is certain the milk is of good quality and has been 
collected in a careful and cleanly manner, need not do more than 
Pasteurize the milk. If he is absolutely certain of the source and 
freshness of the milk he may even give it raw. There are certain 
infants who have an idiosyncrasy against the taking of raw milk. 
The acidity cannot be rectified by lime-water, and the result is that 
such infants will have loose movements or even diarrhoea. These 
cases are exceptional, of course, but they must be borne in mind. In 
exceptional cases the author has seen even Pasteurized milk disagree 
in the same manner with the infant. 

Moreover, we know now that the administration of heated milk, 
especially sterilized milk, over too long a period will cause bone 
disturbances, and it is certainly unwise to give, at least at the present 
day, sterilized milk to infants in the cooler seasons of the year. Even 
with the administration of Pasteurized milk for any length of time, 
it is well at about the fourth to the sixth month of infancy to give 
several times daily a small quantity of diluted orange-juice. In this 
way the ill effects of heated milk are counteracted, and the infant is 
supplied with those salts and acids which are lacking in the Pasteurized 
and sterilized fluid. 

Frozen Milk. 

The process of freezing is deleterious to cowls' milk, inasmuch 
as it breaks up the original emulsion, and milk when thawed does 
not present the normal appearance under the microscope. The 
individual fat-globules are seen to be angular, and instead of pre- 
senting a spherical refracting body, the globule presents concentric 
rings, showing that in some way the cold has acted on the fat. 
Such milk, if given to an infant, will at times disagree and cause 
greenish diarrhoeal movements, sometimes vomiting. Moreover, 
in midwinter it is very common for children who have previously 
been quite regular in their bowel evacuations, with movements of 
normal consistence and appearance, to become constipated as a result 
of the ingestion of milk which has been frozen and then thawed. It 
seems that the fat of the milk undergoes some change which inter- 
feres with its hitherto cathartic action on the bowels. As a result, 
these infants will have hard, constipated movements ; or the move- 
ments may be partly constipated or partly of normal consistence. In 
such cases the physician will have no other resource but to advise 
patience until the milk can be delivered in an unfrozen condition. 

Nursing Bottle. 

The best form of bottle is the so-called Freeman bottle, which 
has very little neck, a wide mouth, not much shoulder to the neck, 
so that it may be easily cleansed. For newborn infants there is 



102 



FOOD PREPARATIONS. 



Fig. 22. 



now constructed a very small bottle of the same model with a 
capacity of three ounces, the idea being that when milk is given in a 
small bottle, the heat is retained during nursing much better than 
when a small quantity of milk is contained in a large bottle. In 
the latter case the milk is chilled before the termina- 
tion of the feeding. When filled the bottles are 
corked .with non-absorbent cotton. They are corked 
loosely, so that the steam may escape. If the cotton 
is jammed tightly into the bottle, the cork will blow 
out in the heating. After nursing, the bottles are 
filled with a solution of washing soda and allowed 
to stand a few hours, and then washed externally 
and internally and drained dry. Any residue of 
milk remaining after nursing should not be utilized 
for another nursing. 

The cleansing of the bottle is carried out with 
a so-called bottle brush. Nipples should be boiled 
once daily for ten minutes, and washed with hot 
water after each nursing. It is well to have several 
nipples carefully sterilized in the early morning and 
kept in a clean jar, rather than in a solution of boric 
acid. If the nipples are kept in boric acid the latter 
is apt to become contaminated, as also the nipples. 
Before feeding, the bottle of milk is warmed to a temperature of 
about 100° to 105° F. (40.5° C), so that the milk may not chill 
the stomach of the infant and thereby suspend the digestive process. 
Dr. Sobel has constructed a bottle-warmer, by means of which the 
milk may be heated to exactly the same temperature at every nurs- 
ing. This is sold under the inventor's name in the shops. 




Nursing bottle 
of the Freeman 
model. 



IV. FOOD PREPARATIONS. 

Peptonized Milk. — With the perfection of our methods of the 
modification of cows' milk, either in the laboratory or at home, the 
use of peptonizing agents as an aid to digestion of the casein of the 
milk has become more and more limited. On the other hand, it 
cannot be denied that the addition of peptonizing substances in safe 
quantities to the milk intended for the infant has a great advantage in 
certain cases of difficult casein digestion. As a rule, the infant will 
not take kindly to completely peptonized milk. It has a bitter 
taste, which cannot be overcome by the addition of sugar or any 
other agent to the milk. We are thus compelled, at least in the 
author's experience, to introduce the peptonizing agent into the milk 
in such a manner as not to change the taste of the food. The best 
method, therefore, of peptonizing the milk for infant-feeding is the 
so-called cold method. This is done as follows : The milk is modi- 



FOOD PREPARATIONS. 103 

fied, either at home or in the laboratory, in the ordinary way. Just 
before giving to the infant, if the amount is from four to six ounces 
at each feeding, one-fifth of a peptonizing tube is added to the 
mixture, which is then well shaken and placed in lukewarm water 
for two and a half minutes, aud then given to the infant. Such a 
milk will not have a perceptibly bitter taste. 

Another method of peptonizing milk for infant-feeding is to 
employ the so-called peptogenic milk poAvder for this purpose sold 
in the shops. A bottle of modified milk containing four or eight 
ounces of the mixture is fortified with about an eighth of a measure 
of peptogenic milk powder just before feeding, heated for seven 
minutes in lukewarm water, and then given to the infant. Infants 
may be kept on this food for months, and then when the digestion 
and powers of assimilation have improved, the peptonization may 
be gradually omitted. The author has seen no ill effects from this 
method of giving peptonized foods. He feels, however, that at 
various intervals during the feeding of such infants, attempts should 
be made to omit the peptonizing ingredients from the mixture, in 
order to see whether the infant cannot thrive without them. 

The indications for the use of peptonizing infant food will be 
given under the heading of Difficult Digestion. 

Condensed Milk. — Condensed milk is very frequently employed 
to feed infants through the whole of the nursing period, and while 
it cannot be denied that some good results are thus obtained, con- 
densed milk, pure and simple, for the majority of infants is not 
available. Many infants w^ill cease to increase in weight under its 
continued use ; others will develop rachitis and scurvy. 

Condensed milk is sold in the shops in hermetically sealed cans, 
with or without the addition of sugar. The sugar is used to pre- 
serve the milk, and is generally cane-sugar. Condensed milk is 
poor in fats, although with the dilutions customary in infant-feed- 
ing, the proteids are not only low, but are in a more absorbable 
state than in most infimt foods. Condensed milk also contains a 
very large proportion of sugar, both milk- and cane-sugar, and this, 
as has been pointed out under the heading of Nutrition, is one of 
the most easily absorbable foods for the infant. 

An infant successfully fed on condensed milk will show a large 
deposit of fat. It may have a very good color, but a critical eye 
will invariably discover evidences of faulty metabolism, such as 
rachitis. Condensed milk is sometimes of great value in cases of 
gastro-enteritis, in which the digestion of ordinary modifications 
of cows' milk seem to be unsuccessful. It should only be used, how- 
ever, in these cases to tide over a critical period. Condensed milk 
may be used fortified with cream, and under such conditions the 
cream is well assimilated. In traveling, also, if good milk is not 
available, infants who have been fed on carefully prepared mixtures 



104 FOOD PREPARATIONS. 

may tide over a period of a few days on dilutions of condensed 
milk. 

The following composition of condensed milk is given by Konig : 

Water. Proteid. Fat. Milk-sugar. Ash. 

Condensed milk without 



, 61.46 11.17 11.42 13.96 1.99 
cane-sugar J 

With the addition ofcane- 1 26.44 10.47 10.07 14.16 2.00 

sugar 38.86 per cent. . J 

In order to prepare condensed milk for infant-feeding, the milk 
is diluted ten to twelve times for infants below three months of 
age, and five to six times for older infants. In the cases of gastro- 
enteritis above mentioned, when the assimilation of cows' milk is 
difficult in the period following subsidence of symptoms, dilutions 
of condensed milk, with the cautious addition of raw cream or top 
milk, are borne better than modifications of cows' milk. This 
method of feeding should be resorted to only after a demonstration 
of the failure of milk modifications, and should only be preliminary 
to feeding with fresh cows' milk. 



Barley-water. 

Barley-water is one of the most useful adjuvants either to modi- 
fied milk mixtures or as an exclusive food for a short time in cases 
of gastro-enteritis. The proper preparation of barley-water has 
been the subject of much study. The simplest method of prepar- 
ing barley-water is that which utilizes the so-called Robinson's 
Patent Barley. A heaping teaspoonful of Robinson's Patent Barley 
is suspended in a pint of cold water until the lumps have disap- 
peared. The mixture is then placed in a small saucepan over a 
gas-stove fire, and stirred constantly for fifteen to twenty minutes 
while boiling. The more the barley-water is boiled, the more 
thoroughly the barley is dissolved and dextrinized. After boiling, 
the loss in bulk is made up to the original quantity by the addition 
of water. The use of the so-called dextrinized barley instead of 
Robinson's Patent Barley offers in certain cases advantages to which 
reference will be made later on. Dextrinized barley is sold in the 
shops as such. It is made up of barley-pearls ground and heated 
for a long period of time according to the formula of J. Lewis 
Smith. The composition of Robinson's Patent Barley is given by 
Konig as follows : 

Water 10.10 

Proteids 5.13 

Fats 0.97 

N.-free extractives (carbohydrates) 81.87 

Ash 1.93 



BEEF-JUICE. 105 

It will be seen by a study of its composition that carbohydrates 
enter into it very largely. Fats and proteids are present in very 
small quantities. It is therefore unavailable as an exclusive food. 

Oatmeal Gruel. — Oatmeal is utilized in the same manner as 
barley to dilute milk. It is made up in the form of a gruel. Two 
teaspoonfuls or more of oatmeal are boiled in a pint of water for 
twenty minutes and then strained. This decoction, made up in 
the same manner as the barley, is utilized to dilute the milk when 
barley has a constipating tendency. 

The composition of oatmeal, according to Munk, is as follows : 

Water 10.1 

Proteids 14.7 

Fat 5.9 

Carbohydrates 64.7 

Kaw fibre 2.4 

Ash 2.2 

Arrowroot Gruel. — Arrowroot gruel has been used from time 
immemorial to dilute milk, especially in cases of summer diarrhoea. 
Dr. Merei is mentioued by Routh as having first suggested the use of 
this cereal for diluting milk. A teaspoonful or two of the arrowroot 
is added to a pint of water and boiled in the same manner as starch 
and oatmeal, strained, and the decoction used as a diluent with milk. 

The composition of arrowroot, according to Konig, is as follows : 

Water 16.50 

Proteids 0.88 

Fat 0.10 

Carbohydrates 81.16 

Eaw fibre 0.05 

Ash 0.19 

Beef-juice. — The principal beef-juices are Valentine's, the prep- 
aration called Puro, Bovinine, Brand's, Wyeth's, Armour's, and 
Burgoyne's preparations of beef-juices. Beef-juices contain little pro- 
tein and much extractive matter, so that the nutritive value is very 
low. There are some of these beef-juices, such as Bovinine, which are 
manufactured from blood rather than beef-fibre. In such a case the 
extractives are few and the proteids low ; they are more in use than 
the other preparations. In order to take enough of these beef-juices 
to equal a teaspoonful of scraped meat in nutritive value, more must 
be taken than could be borne by the average stomach in illness 
(Hutchison). They are not, therefore, available as exclusive articles 
of diet for any length of time, and young children especially, whose 
palates are capricious, will rebel against most of these preparations, 
though they may prefer those which contain less salt than others. 
They are useful, therefore, only as articles of diet twice or three times 
in the twenty-four hours, and furnish ingredients in the shape of 
water and salts and very little protein to the body. 



106 



FOOD PREPARATIONS. 



Composition of Beef-juices. 



Valen- 
tine's.i 



Puro.2 



Bovin- 
ine.3 



Brand.4 



Wyeth.5 



Armour. 6 



Bur- 

goyueJ 



Water .... 
Proteids . . . 
Extractives . . 
Mineral matter 



Per cent. 

51.21 

9.65 

11.16 

10.84 



Per cent. 

36.60 

30.33 

19.16 

9.79 



Per cent. 

81.09 

13.98 

3.40 

1.02 



Per cent, 
59.15 
15.45 
16.55 

8.85 



Per cent. Per cent. 
44.87 74.10 
30 
54 
7.51 



1 38.01 
17.12 



r 8.^ 

I 9. 



Per cent. 

49.51 

13.00 

8.10 

14.20 



Peptone Preparations. — By peptone preparations are meant such 
preparations as Somatose, Carnrick's Peptonoids, Fairehild's Pano- 
peptone, and others. By referring to the table the reader will see 
that there are quite a number of preparations on the market. Of 

Showing the Composition of Peptone Preparations, 



Preparation. 


Water. 


Soluble pro- 
teids (chiefly 
albumoses). 


Extractives 
and other non- 

proteid or- 
ganic matter. 


Mineral 
matter. 




Per cent. 


Per cent. 


Per cent. 


Per cent. 


Somatose 


9.20 


80.00 




6.70 


Carnrick's peptonoids . . 


5.40 


24.00 


65.40 
(mainly sugar) 


5.20 


Koch's peptone 


40.16 


34.78 


15.93 


6.89 


Liebig's peptone ^ . . . . 


31.90 


33.40 


24.60 


9.90 


Brand's beef-peptone . . 


84.60 


7.00 




1.40 


Denaever's peptone . . . 


78.45 


12.15 


4.32 


2.54 


Darby's fluid meat ^ . . . 


25.71 


30.60 


30.18 


13.50 


Armoui-'s wine of peptone ^° 


83.00 


3.00 


12.90 


1.10 


Fairchild's panopeptone^^ 


81.00 


6.00 


13.00 

(largely sugar) 
10.04 


1.00 


Peptonized milk ^^ . . . . 


87.50 


1.76 


0.70 








(= sugar, fat, 










and unaltered 










proteid) 




Liquid peptonoids ^^ 
(Arlington Co.) .... 












5.25 


12.63 


0.95 



the peptonized foods in a ready form, the most concentrated by far 
is Somatose, which contains 80 per cent, of albumoses ; whereas 
other preparations contain, as will be seen by reference to the table, 
very little proteid matter, and are, therefore, of very slight nutritive 
value. Somatose, however, though containing as it does the greatest 

^ Analysis by Dr. Candy. 

^ Fresenius (Leyden's Handbuch der Ernahrungstherapie). 

3 Food and Sanitation, Dec. 23, 1893 (Analysis by Chittenden). 

* Analysis by Dr. Candy (unpublished). 

^ The Lancet Analysis (quoted by the makers). 

^ Analysis by Dr. Attfield (supplied by the makers). 

^ Analysis by Dr. Candy. ^ Leyden's Handbuch der Ernahrungstherapie. 

^ Ibid. See also von Noorden, Therapeutische Monatshefte, June, 1892. 
^° Horton Smith's Journal of Physiology, vol. xii., p. 42, 1891, and Leyden's 
Handbuch. 

^^ Maker's analysis. ^^ Horton Smith {loc. cit). 

^^ Maker's analysis also contains 14.94 per cent, of alcohol by weight. 



BEEF-EXTMACTS. 107 

amount of proteid matter, cannot be taken in large quantities for any 
length of time without causing diarrhoea, and in this respect it is 
unavailable as an exclusive form of food. In feeding infants and 
children I find it is of the greatest value in those cases in which it is 
necessary to give the stomach absolute rest and to feed per rectum. 
For such cases the Somatose is prepared as follows : A teaspoonful 
of Somatose is dissolved in eight ounces of cold water. Two ounces 
of this solution is given carefully per rectum, care being observed to 
pass the catheter above the second sphincter, in order that the food 
may not be rejected. This may be repeated every few hours. Thus 
given, a rectal enema is absorbed for the most part, and in some 
cases it may be mingled with milk part for part, the nutritive prop- 
erties being thus increased. 

Kumyss. — Kumyss has the following composition (Konig) : 

Water 90.44 

Alcohol 1.91 

Lactic acid 0.91 

Milk sugar 1.77 

Proteid 2.44 

Fat 1.46 

Ash 0.42 

Originally kumyss was made from mares' or camels' milk by the 
addition of a ferment indigenous to Tartary, called kefir. To-day 
kumyss is manufactured from cows' milk by the addition of ordinary 
yeast-fungus, and contains, as will be seen by reference to the table, 
a certain amount of alcohol and lactic acid. I have never succeeded, 
even for a short period of time, in feeding infants on kumyss with 
any amount of satisfaction. It is only available in illness of older 
children with capricious palates. It use, therefore, is exceedingly 
limited. The same may be said of Matzoon. 

Beef-extracts. — Beef-extracts are open to the same objections 
as beef-juices, in that they contain for the most part extractives and 
are not intended for prolonged periods of use. There are prepara- 
tions, such as BovriPs, which contain meat-fibre, but which must be 
given in such concentrated form to obtain the necessary nutriment 
as to cause diarrhoea. Beef-extracts, on account of the warmth and 
contained salts, are supposed, when administered, to stimulate the 
appetite. A teaspoonful of BovriFs is equal to 8 grammes of lean 
meat, and therefore must be given in very large quantities, as stated 
above, in order to obtain any amount of nutrition. 

Beef-broth. — Beef-broth has a composition of proteids 0.4, fat 
0.6, salts 1.2, and extractives 1.2. With the extractives beef-broth 
contains creatin, xanthin, and hypoxanthin. 

One pound of meat is cut up, placed in one pint of water, and 
allowed to stand four or five hours. It is then cooked over a slow 
fire for one hour. After cooling, the fat is skimmed off. This 
makes a very agreeable beef-broth. 



108 ARTIFICIAL INFANT FOODS. 

Table Showing the Composition of Beef-extracts} 

Vejos. 



Water .... 
Proteids . . . 
Gelatin .... 
Extractives . . 
Mineral matter 
Ether extract, etc 



Liebig's 


Bovril.3 


Bovril for 


Armour's 


Brand's 


extract. 2 


invalids. 4 


extract.5 


essence. <5 


Per cent. 


Per cent. 


Per cent. 


Per cent. 


Per cent. 


18.3 


44.40 


21.82 


15.55 


87.17 


}.4{ 


16.94 


21.42 


8.73 
2.16 


5.40 
5.03 


30.0 


20.32 


39.60 


43.23 


1.01 


23.6 


18.32 


17.16 


25.91 


1.39 


18.6 






4.12 





Per cent. 
25.02 
19.35 

21.02 
14.07 
17.09 

(Carbo- 
hydrate). 



In addition to the above, beef-broth contains phosphate of cal- 
cium, earthy phosphates, sodium chloride, oxide of iron ; the nutri- 
tion obtained from it depends mostly on the salts, especially of cal- 
cium combined with those of the phosphorus. 

Acorn Cocoa. — Acorn cocoa is a preparation made in Germany, 
and may be obtained on sale in the shops. The author has found 
it of especial use in cases of diarrhoea and intestinal disease in 
which it is advisable to suspend the use of milk. It may be given 
for some days. Some children, however, object to its taste, and for 
this reason it is not applicable in every case. It contains fat, nitrog- 
enous matter, and tannic acid. A teaspoonful of the cocoa is dis- 
solved in eight ounces of water, and the preparation is given warm 
in much the same manner as milk. 

Stohlwerck's acorn cocoa has the following composition : 

Water (Freseni us, Konig) 5.28 

Proteids .' 14.06 

Fat 14.42 

Sugar . 25.15 

Tannates 1.96 

Extractives 23.39 



V. ARTIFICIAL INFANT FOODS. 

Infant foods have been not only the subject of much investigation, 
but the cause of very bitter feeling, both on the part of the profession 
and the manufacturer. Scientifically the physician is correct when 
he maintains that children cannot be brought up, as a rule, on the 

1 Hutchison, The Lancet, 1902. 

'^ Analysis by Tankard. 

^Analysis by Stiitzer (quoted by Voit, Miinchener Medicinische Wochenschrift, 
No. 9, 1897). 

* Analysis supplied by the company. 

^Food'^and Sanitation, Dec. 16, 1893. 

® Analysis by Dr. Candy (unpublished). 

^ The Lancet, April 16, 1898, p. 1060. 

N. B. — " Vejos " is a purely vegetable product, but is included in this table for 
convenience. 



ARTIFICIAL INFANT FOODS. 109 

exclusive use of any infant food. On the other hand, it cannot be 
denied that infant ' foods in combination with cows' milk for short 
periods of time are very useful agents in tiding over many of the 
dyspeptic disturbances of infancy and childhood. It would be, 
therefore, incorrect either to discard infant foods or for the physi- 
cian to regard them with suspicion. They are certainly useful, and 
it will repay the physician to try to understand the indications for 
their use, although it must be confessed that such indications are 
not always evident. An infant food, therefore, may be regarded 
as a carefully prepared article of diet, to be used with discretion 
in a limited number of cases of difficult feeding in infancy and early 
childhood. I do not hesitate to say that some of the most difficult 
cases coming under my observation have thriven on the judicious 
combination of an infants' food with cows' milk. We must under- 
stand, however, in giving the infant foods the exact indications in 
the case. They must net be given emiiirically. 

The infant foods present to the practitioner either dried milk, a 
cereal in combination with it or alone, with or without the addition 
of a malt preparation of some kind. It is quite evident, therefore, 
that there are several serious objections to them as exclusive articles 
of diet for a great length of time. The principal objection is that 
they are dried or heated food substances. In a majority of cases 
this is a dangerous article to use for a prolonged period in infancy 
and childhood without combining it with some fresh article of diet, 
such as cows' milk. 

Again, many of the infant foods contain nothing but a dry, care- 
fully prepared cereal. It is evident that this alone cannot be given 
as an exclusive article of diet to an infant. It may be administered 
for a short time, as will be pointed out in the article on Infant- 
feeding ; but it cannot be given for any prolonged period without 
giving rise to those very symptoms which we all fear in the feed- 
ing of infants, referable to the bones and the circulatory system ; 
in other words, evidence of disturbed nutrition, such as rachitis and 
scurvy. Infant foods, therefore, if judiciously employed, are useful 
in the hands of a careful physician where other methods fail, but only 
as adjuncts to well-recognized forms of food, such as cows' milk. 

We may divide infant foods roughly into three groups : The 
first group, such as Allenbury's, Horlick's, Carnrick's, and Nestl^'s 
Food, contain cows' milk desiccated, combined with some cereal and 
sugar. These foods are intended as an exclusive diet for infants, 
and against these the scientist objects principally. They are foods 
which cannot be applied but in a very small percentage of cases as 
an exclusive food, and which if given over a prolonged period are 
open to the objections stated above. 

The second group of infant foods are possibly the most useful, 
and are those which contain some form of malted carbohydrate. 



110 ARTIFICIAL INFANT FOODS. 

The carbohydrates are in soluble form aud the food may be re- 
garded as a desiccated malt extract. Some of these preparations 
also contain diastase, and by combining the food with cows' milk 
or by the addition of some carbohydrate to the milk we can ob- 
tain a combination which is not only digestible for the infant, but 
may be of great nutritive value for a short period of time. In 
this group belong Mellin's Food, Loeflund's Malt Soup, the latter 
being nothing more nor less than the Liebig Malt Extract combined 
with potassium carbonate. 

The third group of infant foods are those which are constructed 
of a pure cereal, and in this group are Ridge's Food, Imperial 
Granum, Robinson's Patent Barley, and others. This last group 
may simply be considered as very carefully prepared cereals. They 
are very useful in that we may apply them in those cases of in- 
testinal disorder in which it is desirable for a short period of time 
to exclude milk completely. 

If we study all these foods, including condensed milk pre- 
viously mentioned, we shall see that they show a deficiency of fat 
and an excess of carbohydrates. On this ground alone their pro- 
longed use is objectionable. The proteids present are either in the 
form of dried, heated proteids of cows' milk, one of the most in- 
digestible forms of proteid substances that can be given to the infant, 
or in the nature of vegetable substances which are foreign to the infant 
dietary. Condensed milk also contains such an excess of sugar as to 
cause acid dyspepsia ; although preparations of condensed milk are 
made up, as has been stated, without sugar. In the treatment of 
enteritis, both of the acute and subacute type, it is essential in very 
young infants to give temporarily some form of food which does not 
contain milk in any form. Although an ordinary cereal may be 
used in these cases, a more agreeable form is one of the infant foods, 
and especially Imperial Granum. This, made up to the consistence 
of ordinary barley-water, may be administered in cases of ileocolitis 
for quite a length of time, and will not be rejected by the infant or 
young child. 

At the period of w^eaning — the ninth month — cereals may be 
added to the milk, in the form of an infant food, such as Ridge's 
Food, Imperial Granum, or barley. In such cases not only is 
the barley or infant food well borne, but the cereals aid diges- 
tion in breaking up the casein, which at this period is given in 
the milk in four times the quantity present in the human milk. 
Infants who suffer from colicky pains in casein digestion will be 
remarkably free from them if some form of cereal is added to the 
milk, and in some cases a malted food, such as Mellin's, added to 
the milk will aid digestion and set aside troublesome symptoms. 
It must not be forgotten also that in the malted foods, when added 
to the milk, we are giving a form of sugar, malt-sugar, one of the 



ARTIFICIAL INFANT FOODS, 



111 



most digestible carbohydrates. This alone, in combination with 
other carbohydrates in the infant food, not only aids digestion, but 
also the increase in weight. 

The objection raised to the combination of malted foods, starchy 
cereals, and milk, that the infant is not capable of digesting starch, 
does not obtain fully in practice. We find, as will be shown in 
case of the dextrin ized gruels, that large quantities of carbohydrate 
and flour may be given to infants, and their digestion will not only 
be normal, but they will thrive and increase in weight very rapidly ; 
whereas, under an ordinary milk diet they have remained atrophic. 





Composition 


of Infant Foods? 


Food. 


i 


1 








General description and remarks. 




aS 


o 


+i 


f-' >. 


^ ^ 






1 


£ 


^ 


6^ 


i 






Per 


Per 


Per 


Per 


Per 






cent. 


cent. 


cent. 


cent. 


cent. 




Dried human milk . . 




12.20 


26.40 


52.40 


2.10 


The standard of composition to which 
artificial substances should con- 


Group I. 












form. 


Allenbury No. 1 . . . 


5.70 


9.70 


14.00 


66.85 


3.75 


Desiccated cows* milk from which 


(For children before 












the excess of casein has been re- 


the age of three 












moved, and a certain proportion of 


months.) 












soluble vegetable albumin, milk, 
sugar and cream added. No starch 

present. 


Allenbury No. 2 . . . 


3.90 


9.20 


12.30 


72.10 


3.50 


Resembles the above, but contains 


(For children from 












some malted flour in addition. No 


the age of three to 












starch present. 


six months.) 














Horlick's malted milk 


3.70 


13.80 


3.00 


76.80 


2.70 


A mixture of desiccated milk (50 per 
cent.), wheat flour {2&\4 per cent.), 
barley malt (23 per cent.), and bi- 
carbonate of soda {% per cent.). 
Contains no unaltered starch when 
mixed. 


Carnrick's soluble food 


5.50 


13.60 


2.50 


76.20 


2.20 


A mixture of desiccated milk (37^^ 
per cent.), malted wheat flour (373^ 
per cent.), and milk-sugar (25 per 
cent.). When prepared according 
to directions the casein is partially 
digested, but a considerable amount 
of unchanged starch is left. 


Nestl6's milk food . . 


5.50 


11.00 


4.80 


77.40 


1.30 


A mixture of desiccated Swiss milk, 
baked wheat flour, and cane-sugar 
(30 per cent ). More than a third 
of the total amount of carbohy- 
drate is in the form of starch. 


Manhu infant food . . 


8.86 


8.70 


5.60 


75.90 


1.00 


A mixture of desiccated milk and 
malted cereals. When prepared 
according to directions contains a 


Group 11.— Class A. 












good deal of unaltered starch. 


Mellin's food 


6.30 


7.90 


trace 


82.00 


3.80 


A completely malted food. All the 
carbohydrates in a soluble form. 
May be regarded as a desiccated 
malt extract. 


Class B. 












Savory & Moore's food 


4.50 


10.30 


1.40 


83.20 


0.60 


Composed of wheat flour with the 
addition of malt. 














Benger's food 


8.30 


10.20 


1.20 


79.50 


0.80 


A mixture of wheat flour and pan- 
creatic extract. 


Allenbury malted food 


6.50 


9.20 


1.00 


82.80 


0.50 


A mixture of wheat flour and malt. 
When prepared according to direc- 
tions it still contains some unal- 
tered starch. 



^ Robert Hutchinson, Lancet, 1902. (Modified. ) 



112 



MATERNAL NURSING. 



Composition 


of Infant 


Foods {Continued). 


Food. 


-2 


•6 
■-2 




q5 

^1 


1| 


General description and remarks. 




1 


2 


i 


S^ 


■l« 




Group 11.— Class B 


Per 


Per 


Per 


Per 


Per 




{Continued). 


cent. 


cent, 


cent. 


cent. 


cent. 




Diastased farina . . . 


8.30 


7.60 


1.30 


81.70 


1.10 


A malted farinaceous food. When 
prepared according to the direc- 
tions, practically all the starch is 
converted into soluble forms. 


Coomb's malted food 


7.90 


12.10 


2.80 


76.80 


0.40 


A malted farinaceous food. 


Nutroa food 


6.80 


15.90 


10.30 


66.00 


1.00 


A mixture of cereals with the addi- 
tion of a certain proportion of pea- 
nut flour, from which the some- 
what bitter taste of the food and its 


Group III. 












high proportion of fat are derived. 


Ridge's food ..... 


7.90 


9.20 


1.00 


81.20 


0.70 


A baked flour, containing only 3 per 
cent, of soluble carbohydrates, the 
remainder being starch. 


Neave's food 


6.50 


10.50 


1.00 


80.40 


1.60 


Resembles the above. 


Frame food diet . . . 


5.00 


13.40 


1.20 


79.40 


1.00 


A thoroughly baked flour to which 
have been added cane-sugar and 
some extract of bran. 


Opmus food 


10.90 


9.10 


1.00 


78.60 


0.40 


A granulated wheat food. 


"Falona" 


7.00 


8.40 


3.50 


79.90 


1.20 


A mixture of cereals (oats, barley, 
and wheat), with a ground fat- 
containing bean. 

Ground oats from which the husk 


Robinson's groats . . 


10.40 


11.30 


1.60 


75.00 


1.70 














has been removed. 


Robinson's pat. barley 


10.10 


5.10 


0.90 


82.00 


1.90 


Ground pearl barley, poor in every 
element except starch and mineral 


























matter. 


Chapman's whole flour 


8.40 


9.40 


2.00 


79.30 


0.90 


A finely ground whole-wheat flour. 


Scott's oat flour . . . 


5.80 


9.77 


5.00 


78.20 


1.30 


A fine oat flour. 


Addenda. 














Imperial granum . . 


9.23 


14.00 


1.04 


75.34 


0.39 


(Classified under Group III.) 


Eskay's food 


8.58 


5.82 


1.16 


89.02 


1.30 


(Classified under Group I.) 



VI. MATERNAL NURSING. 

The ideal food for the infant is the milk of the mother^ s breast. 
Under our social conditions, the mother who can nurse her child 
from birth to the period of weaning is an exception to the rule, not 
because most mothers do not wish to nurse their infants. On the 
contrary, the author has found them very anxious to perform this 
function, but the average mother to-day has not the physical devel- 
o]3ment that fits her to nurse the child. The result is that she 
cannot furnish sufficient milk, or that the milk is not of the quality 
requisite for successful nursing. Some mothers will have a suffi- 
ciency of so-called milk. The infants, however, do not gain in 
weight, are puny, have attacks of colic, and the symptoms indicate 
that the food is at fault. Examination shows that in such women 
true milk secretion is rarely established; the milk remains in the 
colostrum stage. 

Some physicians think that if the infant cannot have the benefit 
of the maternal breast a wet-nurse is the alternative. If with the 
wet-nurse we had only to consider the fitness of the food, this would 



CONTRAINDICATIONS TO MATERNAL NURSING. 113 

be true. If the maternal breast is not at our disposal, the next best 
and the safest thing for the race is a substitute for the breast, for 
many reasons, some of which we will try briefly to indicate. 

In the first place, it is not moral nor conducive to the future 
good of the race to ask a mother (the wet-nurse) to put aside her 
own child and to deprive it of the breast for the sake of a strange 
child. 

Second. No matter how healthy a wet-nurse may be at the 
time of examination, we have no assurance that such a wet-nurse 
will remain healthy, or that some diathesis not apparent at the time 
of examination may not be transmitted to the infant. We thus take 
a healthy infant, place it at a breast, and feed it with milk con- 
cerning the ultimate influence of which we are utterly in the dark. 
The author is inclined to believe tha;t so far as human milk is con- 
cerned, certain tendencies may be conveyed from the nurse to the 
infant which will crop out later in life. By this he refers rather 
to scrofulous tendencies, lymphatic tendencies, tendencies connected 
with diseases of the blood-forming organs. 

Third. The introduction of a stranger into the household is a 
cause of great disturbance to that household, and also one of concern 
to the physician. The idea that a child brought up at the breast is 
better fitted for the struggle of existence may be true ; on the other 
hand, the difficulties, at least in this country, of obtaining fit wet- 
nurses for children are so great that it would be well, if the mother 
cannot nurse the infant, to place it on a substitute in the form of 
bottle-feeding, unless this is not feasible. 

Of course, in all of this Ave do not include those exceptional 
infants which cannot be fed artificially. Such cases occur, and must 
be placed upon the breast. 

Finally, if the mother can furnish two or three nursings daily, it 
is well not to take the child off" the breast entirely, but to institute 
what is known as mixed feeding. In some cases this is a very satis- 
factory method of feeding the infant. 

Contraindications to Maternal Nursing. 

A mother may suffer from syphilis or skin eruptions or may have 
a deficiency of milk and under certain conditions may still be allowed 
to nurse her infant. A wet-nurse should be free from all constitu- 
tional and psychical taint to be fit to nurse an infant. 

Syphilis can be communicated to the wet-nurse by the infant, or 
to the infant by the wet-nurse through luetic lesions of the nipple. 
A syphilitic infant, therefore, must not be allowed to nurse the 
breast of a woman who is free from syphilis ; and we should be 
very careful not to place a child free from syphilis on the breast of 
a wet-nurse without previous careful examination as to the presence 
8 



114 MATERNAL NURSING. 

of syphilis in the nurse. A mother, on the other hand, who has 
syphilis can nurse her infant without danger of communicating 
syphilis to the infant if the mother has been exposed to and con- 
tracted the disease up to a period of two months l3efore the delivery 
of the child. An infant congeni tally syphilitic may nurse its mother 
without communicating the disease to the mother. These facts have 
been well established, and have been commented on in the chapter 
on Syphilis. Should the mother have contracted syphilis subse- 
quent to the birth of her infant, and should she have been nursing 
the infant, it would be wise to take the infant away from the breast, 
for such a mother may communicate the syphilis to the infant in the 
same manner as a syphilitic wet-nurse. 

Tuberculosis in the mother, if active, even in its milder mani- 
festations, is a contraindication to her nursing her infant. Though 
the manner in which the toxins of the tubercle bacillus or the 
bacillus itself pass into the breast milk, if such be the case at all, is 
still a matter of study, we can well understand how the mother, 
weakened by the inroads of such a disease as tuberculosis, would be 
further seriously injured and weakened by nursing her child. The 
close contact of mother and nursling, furthermore, mio^ht favor the 
infection of the infant in other ways than by the milk alone. On 
the other hand, an old focus of tuberculosis, such as a healed pleurisy 
or coxitis long healed, in a vigorous mother would not contraindicate 
nursing should the secretion of milk be abundant and should the 
function not make inroads upon her health. 

Active symptoms of Bright's disease, such as general anasarca 
and other signs of serious involvement of the kidney, would preclude 
a mother's nursing her infant, not only because such a function 
would weaken her, but because, metabolism being profoundly dis- 
turbed, the breast milk would be unfit for the maintenance of the 
nutrition of the infant. 

Advanced disease of the heart would also unfit a woman for 
nursing her infant. On the other hand, a slight albuminuria not 
giving any objective or subjective symptoms should not interfere 
with the desire of the mother to nurse her offspring. Advanced 
and active disease of the liver would in the same manner as the 
above diseases contraindicate nursing. 

Organic nervous disease with paralysis, severe neuroses, insanity, 
hysteria, epilepsy, neurasthenia of a marked type, when present 
in the mother, contraindicate the nursing of the infant. Aside 
from the disturbances said to be caused in the infant nursing the 
breast of a person the subject of hysterical or epileptic attacks, 
we would scarcely care to trust such a sufferer with the care of an 
infant. On the other hand, slight nervous tendencies in the mother 
should not contraindicate the nursing of the infant, for in such a 
case we would open the way for the deprivation of the breast to a 



SELECTION OF A WET-NURSE. 115 

large number of infants, and give an easy avenue of escape to some 
from the responsibilities of maternity. The severe forms of anaemia, 
leucaemia, malignant disease, such as carcinoma and sarcoma, the 
presence of a very marked goitre with active symptoms, may be 
mentioned as contraindications to the nursing of an infant. 

The acute contagious diseases, the exanthemata, erysipelas, pneu- 
monia, bronchopneumonia, pleurisy, acute rhematism, typhus and 
typhoid fever, diphtheria, are all contraindications to nursing the 
infant. A woman may be in the convalescent stage of typhoid and, 
if strong, may be allowed to nurse her child. I have seen mothers 
suffering from erysipelas nurse their infants without infecting them. 
This should not be the rule, however. In a case of diphtheria the 
danger to the infant of infection is much greater than would be 
counterbalanced by the benefits to be attained from continuance at 
the breast. The milk of a woman suffering from a severe pneu- 
monia with a high febrile curve cannot be all that is desired for the 
infant, and the process of nursing with the accompanying physical 
and mental disturbance might react against the mother. 

Selection of a Wet-nurse. 

It is not necessary that the wet-nurse should have been recently 
delivered. A new-born baby may be given the breast of a nurse 
whose baby is from one to tw^o months of age. In fact, her milk is 
preferable to that of a nurse who has just been confined. For, apart 
from the uncertainty as to whether the milk will agree with the 
baby, the milk after a few weeks attains a uniform composition, and 
is more likely to agree with the baby than milk from the breast of a 
woman recently confined. I prefer to place the newborn infant on 
a breast at least three weeks old. 

The method of examining a wet-nurse as to her fitness begins 
with ascertaining the history of her own baby. It should sleep well 
in the intervals of nursing, be free from colic, and have normal 
movements. The baby should be completely undressed for exami- 
nation. It should be at least tolerably well nourished. There 
should be no eruption on the skin, no copper-colored intertrigo, 
no snuffles, no pigmented spots, and no rhagades around the 
mouth or anus. The skin of the palms of the hands or the soles 
of the feet should not be fissured or hard or present suspicious pig- 
mentation. The head should not have an idiotic, microcephalic 
conformity. The wet-nin\se should be below the age of thirty. Old 
multiparse do not, as a rule, furnish good milk. The shape of the 
breast is important. The pear-shaped, elongated, hanging breast 
furnishes more milk than the firm, round breast of virgin shape 
(Plate IV.). The nipple should be about one centimetre long and 
three-fourths of a centimetre in diameter. The baby can easily 



116 MATERNAL NURSING. 

grasp such a nipple and draw it into the mouth. A flat nipple, or 
a nipple with fissures, or a nipple surrounded by eczema is not 
desirable in a nurse, and may even be dangerous to an infant. The 
nurse is next directed to undress, and her body is examined for 
traces of any eruption which may be specific. Pigmented macules 
should arouse suspicion, as also enlarged cervical or epitrochlear 
lymph-nodes. The lungs, especially the apices, are examined for 
bronchitis or tuberculosis. The nurse is rejected if there be the 
slightest evidence of apical involvement. The teeth should not be 
carious to such an extent as to preclude the possibility of their being 
kept clean. The presence of a foetid ozsena is highly objectionable, 
apart from the offensive odor. Such cases may be latently tuber- 
culous. The woman should be mentally sound. The wet-nurse is 
then examined as to the presence of venereal disease by inspection 
of the introitus vaginae and the anus. The mucous membrane of 
the mouth should be examined for evidences of syphilis. Search is 
made for mucous patches and suspicious cicatrices. After having 
exauiined both child and mother in the manner detailed, Ave are in 
a position to recommend the nurse if the milk is satisfactory. 

The physician should have at hand in his office means by which 
he can at once decide upon the desirability of a wet-nurse. He must 
not at the beginning be driven to the necessity of a milk analysis. 
He decides first as to the quantity and then as to the quality of the 
milk. As a rule, a wet-nurse comes to the physician insufficiently 
fed and in a frame of mind far from tranquil. If despite these 
conditions the milk possess the qualities desired, he may at once 
venture to place the baby at the breast. If the milk does not agree 
with the baby after a fair trial, future conduct will be guided by 
certain developments, both in the quantity and quality of the milk 
and the condition of the infant. 

Quantity of the Milk. — The physician grasps the breast in the 
palm of his right hand and gently but firmly attempts to express 
the milk. The milk should with gentle pressure flow^ freely from the 
ducts. A drop is caught on the nail of the thumb. This time- 
honored nail-test is not to be despised. A drop of good milk 
will retain its bluish-Avhite tint. This test will bring out the color 
of the milk, Avhether too watery, yellow, or white, to the experienced 
eye. The nurse is then directed to pump by gentle pressure a 
quantity of milk into a long, narroAV beaker glass. If the breast 
has not been nursed within an hour, there should be no difficulty in 
obtaining at least an ounce of milk in this Avay. With this quan- 
tity Ave can at once decide on the efficiency of a nurse. The milk 
should have a bluish-white tinge. Any trace of yelloAV or green 
when a test-tube of the milk is held in the light, is abnormal. 
Milk may be very abundant but of a dirty white tinge ; some 
specimens separate almost instantly upon withdraAval into a yel- 
lowish oily layer on top and a serous liquid below. Any such ab- 



PLATE IV, 

FIG. 1. 




Form of the Breasts of a Wet-nurse with Abundant 

Milk of Good Quality. (Af.er Sehliehter ) 



FIG 2. 




Fornri of the Breasts of a Wet-nurse whose Milk is 
Deficient in Quantity and Quality. (After Sehiiehter.) 



SELECTION OE A WET-NURSE. 117 

normalities in the milk should cause the rejection of an applicant. 
If the breasts, history, and physical examination are satisfactory, 
and the quantity and physical characteristics of a nurse's milk are 
good, we may recommend her without making a chemical examina- 
tion of the milk. Such an examination is impracticable for the 
practitioner with the means at his disposal. Even if carried out, it 
may be unfair to the nurse. At the examining visit the proportion of 
proteids and fats may be below what it will adjust itself to in a day 
or two when the wet-nurse is rested and housed in her new home. 
More nutritious diet will greatly change the composition of the milk. 
There are, however, conditions which may require an examination 
of the milk at a subsequent period. In such a case the methods 
detailed elsewhere may be resorted to. 

Once having determined to place the infant at the breast, the 
question arises. When should this function be begun ? Immediately 
after birth the mother is tired and so is the infant. They have both 
gone through a critical period. It is well to let them rest for some 
hours. If the infant sleeps, and awakens only to be changed as to 
its diaper, we should not hasten to feed it. The author follows the 
rule that the infant be given a little water at intervals from the first 
six hours until the beginning of the next day after birth, and then 
the mother, having been thoroughly rested, the child is put at the 
breast, even though there are but a few drops of colostrum in the 
breast. 

The first day after birth the infant should be fed at intervals of 
three hours. At this time there will be very little in the breast, 
but the stimulation of the breast by nursing will cause an in- 
creased secretion of milk, so that by the second day nursing may be 
inaugurated at regular intervals of two hours. After this the inter- 
vals of nursing are so apportioned that the newborn infant during 
the first week will obtain * the breast from nine to ten times in the 
twenty-four hours ; the second week, eight or nine times in the 
twenty-four hours ; and in the fourth week, eight times in the 
twenty-four hours. After this the intervals of nursing will be much 
the same as they are in artificial feeding. We give the breast at 
intervals, generally of two and a half hours, so that the last nursing 
is at 11 p. M. After the first month the infant should sleep until 
five or six o'clock in the morning, when it obtains the first nursing. 
Then from the second to the sixth month seven nursings in the 
twenty-four hours are sufficient. The nursing should be so arranged 
that the mother and child may have complete rest of five hours 
between 12 p. M. and 5 A. m. 

The number of times an infant should nurse at the breast is in 
the large majority of cases a matter of training and habit, especially 
with the breast-fed infant. Czerny, following, Ahlfeld advises plac- 
ing the baby at the breast on the average of five times in the twenty- 
four hours. With care and patience this can be done. The practi- 



118 MATERNAL NURSING. 

tioner, however, will meet a number of mothers who will nurse their 
offspring more frequently, and the above gives the limit of such 
nursings. In frequent nursing the infant receives less at each feed- 
ing than in the nursings at longer intervals. 

The care of the breast really begins before the birth of the 
infant. About the seventh month of pregnancy colostrum appears 
in the breast. At this time it can be seen in some cases to exude 
from the nipple. Unless care is taken at this time we will have a 
fissuration of the breast nipple, due to the action on the epithelium 
of the skin of the drops of colostrum which are allowed to col- 
lect and to decompose on the nipple. The result is that at birth 
the mother may have sufficient milk in the breast, but be unable to 
nurse the child on account of the presence of these fissures. I 
advise, therefore, that at this time of pregnancy the nipples be kept 
scrupulously clean and washed twice a day with a dilute solution of 
alum water or some antiseptic wash. In this way the decomposi- 
tion of colostrum on the nipple is avoided, and the nipple is strength- 
ened by the slight massage of washing. If the nipple is not well 
developed, this is the time also to attempt its development. This 
is done by drawing out the nipple twice a day, either with the clean 
fingers or by means of suction. A small clay pipe may be used for this 
purpose, and the future mother may draw out the nipple by means of 
suction with this simple instrument. I am certain if this hygiene of 
the nipple is pursued that fissures of the nipple will be less frequent. 

Fissured Nipples. — Ordinarily, if the nipple of the breast is kept 
dry and clean, it will not fissure and eczema will not occur. Fis- 
sures, however, sometimes occur even when great care has been 
taken to prevent them. Fissures or rhagades appear in about one- 
half of the nursing women. They are present either on the summit 
of the nipple or at its base. In the latter situation they are in the 
form of linear or circular ulcers. If fissures of the nipple are pain- 
ful, the infant should not nurse the breast directly, but through a 
shield which protects the nipple, the best form being the Davidson 
shield. The fissure is painted once daily with a 10 per cent, solu- 
tion of nitrate of silver. If there is a discharge of visible pus from 
the fissure, or if the breast nipple has a point of suppuration ever so 
small, the breast should not be nursed by the infant, for by so 
doing the mother may develop abscess of the breast or the infant 
may contract an infectious diarrhoea. 

Physicians insist on placing infants at the breast immediately after 
delivery, for two reasons : first, because it is said that suction at 
the breast favors contraction of the uterus. Whether with this 
function there is contraction of the uterus has not been proved. 
Again, it is said that at this time suction will favor the flow of milk. 
Milk with colostrum does not appear to an appreciable amount in 
the breast, if not previously present, before twenty-four to seventy- 
two hours or even eight days after delivery. If, as has been pointed 



CAKING OF THE BREAST. 119 

out, the breast is nursed too frequently, the traumatism caused by a 
vigorous infant will give rise to erosions of the nipple, and thus 
fissures. An excellent nursing breast may be ruined by over- 
zealous efforts on the part of the physician. Fissures once present, 
if unyielding to the methods detailed above, must be allowed to heal 
by giving the breast perfect rest. Some women will nurse an 
infant at the breast, the nipples of which are the seat of fis- 
suration, without pain, caking, or inconvenience. In other women 
caking will take place, with intense pain on nursing, and lym- 
phangitis and abscess result. In all such cases of pain, lymphan- 
gitis, and cakiug nursing is best suspended, the infant being placed 
temporarily on the bottle. The breasts are supported, the fissures 
painted daily with silver, and if caking is present the breasts are 
emptied carefully with the pump and massage of the breast per- 
formed. If after the breasts become soft and the fissures are entirely 
healed there is still a little milk in the breast, the infant may be put 
again at such a breast, and if the organ is in a normal state the 
stimulation of suction will start a proper milk secretion. I have 
done this in a case in which the breasts had been at rest for three 
weeks after delivery, with excellent results. The milk returned in 
abundance, without unnecessary traumatism to the breast, the infant 
nursing only three times daily at first. We should never expose a 
mother to the danger of abscess of the breast by persistent attempts 
at mussing fissured nipples. 

Caking of the Breast. — After the birth of the infant, the breast 
should be closely watched to prevent the so-called caking of the milk. 
If the infant is not strong and does not nurse well, there will be a 
residual amount of milk in the breast. After nursing, this milk 
should be pumped off with a breast-pump. The most satisfactory 
breast-pump is one with a glass bell and a rubber bulb. Pumping 
the breast at first, wiien the milk is forming, Avill prevent caking and 
rapidly regulate the secretion to the normal amount. On the other 
hand, if a fissure of the nipple is present, caking is more apt to 
occur, on account of the pain attendant on emptying the breast, either 
by nursing or by means of the breast-pump. We should be exceed- 
ingly cautious in these cases to examine the breast repeatedly in order 
that areas of caking may not escape us. 

If caking occurs, the breast should be rubbed or massage per- 
formed three times daily. The hands of the nurse are carefully 
washed, and anointed with some sterilized oil. The breast is grasped 
in the palms of both hands, one above and the other beneath. The 
breast is then gently subjected to firm pressure with a vermicular 
motion. This massage is kept up for five or ten minutes. 

Nursing the Infant. — The infant should nurse about tw^enty 
minutes and then fall asleep at the breast. The nipple is washed 
with a solution of boric acid before and after each nursing, and is 
covered in the intervals of nursing with a small piece of absorbent 



120 MATERNAL NURSING. 

gauze folded several times. In this way the nipple does not come 
in contact with the clothing, and any exuding milk is caught on the 
gauze, which is replaced by a clean piece whenever necessary. The 
infant while nursing should lie in the arms of the mother or the 
nurse. The nurse grasps her breast just behind the base of the 
nipple with the index and ring fingers ; the thumb should be used 
to exert pressure on the breast and thus regulate the flow of milk. 
In this way the infant is prevented from drawing the nipple too far 
into the mouth. The habit of moistening the breast with saliva or 
a few drops of milk is reprehensible. The infant's mouth will 
furnish all the moisture needed. 

Signs of Efficient Breast-feeding. — An infant nursed at the 
breast is thriving if it has a good color, if its weight increases in 
regular ratio, if it sleeps between the nursings, and the stools are 
normal in color. It may be said in this place that, as to the stools, 
they will vary even in the most thriving infant, both in color and 
consistence, from time to time. An infant who is otherwise in good 
health and is not suffering from any disturbance of the gut will have 
from time to time slightly fluid, yellow movements ; at other times 
the movements may contain a few whitish curds ; and at other periods, 
even the most thriving breast-fed infants may show in the stools 
greenish discolored particles. If the infant shows no other signs of 
disturbance and is in good spirits, these changes in the color and 
consistence of the movements should not give us concern ; they are 
dependent on the varying composition of the breast milk. If the 
milk contains on certain days more fat than usual, the movements 
may be softer and more frequent than customary. If the proteids 
are increased in quantity they may even show a greenish tinge. 
These conditions, however, must be infrequent and should not carry 
with them disturbances, such as colic, restlessness, or stationary 
weight. I have seen infants who were thriving, in that they had a 
very good color and their weight increased, but they suffered from 
inordinate colic, and examination of the breast milk showed, even at 
the second month of infancy, quite a number of colostrum corpuscles. 
After certain hygienic hints were carried out by the mother, these 
colostrum corpuscles disappeared from the milk, the colic abated, 
and the infant returned to a normal condition. Disturbances, there- 
fore, of the gut are not always an indication for the cessation of 
maternal breast-nursing. 

Signs of Inefficient Breast-feeding. — An infant is not thriving 
on the breast milk if its weight remains stationary for any length 
of time. For this reason infants should be weighed once a week at 
first, and after the second month at least twice a month. At the 
first indication of stationary weight an infant should be weighed 
every three days, in order to see whether there is any increase under 
new conditions. If the weight continues stationary the milk should 
be examined. It may be deficient in quantity to such an extent as 



SIGNS OF INEFFICIENT BREAST-FEEDING. 121 

to no longer satisfy the child. In that case the infant will be ob- 
served to nurse the breast for a long time, or it may nurse the breast 
a short time and then relinquish the nipple and cry ; or it may cry 
in the intervals of nursing. All these are signs of inefficient feed- 
ing. In such cases the breast should be examined just before a 
regular nursing, in order to estimate the quantity of milk in the 
breast. The infant should be weighed, then given the breast, and 
weighed after nursing is completed. The breast is also examined 
after nursing. In this systematic way we can estimate the amount 
of milk taken by the infant at that particular nursing. 

The movements of infants fed on an inefficient breast as to the 
quantity of milk are dry, constipated, and small. The author has 
seen the character of the stools improve upon increasing the quantity 
of food, either from the breast or by supplementing the breast with 
the bottle. In some cases the infant cries and has colic, the move- 
ments are passed with much flatus, and are uneven in consistence, 
lumpy here and there, with green discoloration. In such a case the 
quantity of the milk may be sufficient, but its quality is not up to 
the requisite standard. The nurse's milk should be examined not 
only chemically, but microscopically. A single chemical examina- 
tion of the milk, as has been stated, gives no definite information. 
The milk, therefore, of the morning and evening nursings should be 
examined. It may again be emphasized that colic alone or com- 
bined with slight variations in color and consistence of the infant's 
stools is not a justification for the suspension of nursing. An infant 
may gain in weight, have good color, and still have inordinate colic. 
With patience and hygienic exercise on the part of the nurse colicky 
attacks will ultimately grow less frequent, and many infants who 
suffered colic at first will, as the second month approaches, cease 
to have colic as soon as the milk has definitely assumed a uniformly 
normal composition. Infants who thus have suffered colic at the 
second or third month after birth will cease to be inconvenienced 
and will thrive from this time forward. 

If an infant at the breast fails to increase in weight, and at the 
same time suffers from inordinate colic, has green, curdy movements 
or a slight tendency to diarrhoea, it becomes a very important ques- 
tion as to whether it is not better to take such a child from the 
breast entirely, and to place it either on another breast or a substi- 
tute for the breast. An examination of the breast milk will aid us, 
as has been intimated elsewhere. If this breast milk reveals to any 
marked degree elements such as colostrum corpuscles and fails to 
show the characteristics of normal breast milk, we will still be more 
anxious to take such an infant from the breast. In fact, a con- 
tinuation of an infant at such a breast is sometimes not devoid of 
danger. In one case the continued attacks of colic, accompanied by 
fluid movements, with green curds from birth, resulted ultimately in 
an attack of intussusception. This occurred in an infant five months 



122 MIXED FEEDING. 

of age. After the operation the infant was placed on the mother's 
breast again, and had a return of the former symptoms — constant 
colic, green curdy movements, alternating at times with slight diar- 
rhoea. It was taken off the breast immediately, placed on an artifi- 
cial substitute, and throve. 

VII. MIXED FEEDING. 

Mixed feeding is the administration of the breast, supplemented 
by the bottle containing some substitute for the milk lacking in the 
breast. Infants who are nursed on an inefficient breast as regards 
quantity of milk should be carefully weighed, and the quantity of 
milk in the breast estimated for the twenty-four hours. This may 
be done by weighing the infant before and after each nursing, or 
can be roughly estimated by simply observing the amount of milk 
that can be pumped oif from both breasts combined two hours after 
a feeding. Having measured the milk, we can estimate within cer- 
tain limits the amount of milk which such a breast would yield in 
twenty-four hours. If there is sufficient milk in the breast for two 
nursings, the mother should not be denied the pleasure of nursing 
her infant. We should not hastily reject such a breast as worthless, 
for two feedings of breast milk will be a great aid to the infant, 
both in the development of bone and the other tissues of the body. 
If two nursings exist in the breast, we would give the bottle six 
times in the twenty-four hours to an infant below the age of three 
months, and five times in the twenty-four hours to an older infant. 
In feeding on the bottle in combination with the breast, we should 
begin as we do in the newborn, with a low percentage of fats and 
proteids. Having accustomed the infant to the bottle, we should 
gradually work up to the normal percentage of fats and proteids, as 
will be shown in the chapter on the Feeding of Infants. The details 
as to the construction of the food are the same as those followed out 
with the infant fed upon the bottle exclusively. Care should be ex- 
ercised in these cases to avoid overfeeding. Mothers are especially 
prone to overfeed infants, having an idea that a fat baby is a 
healthy one ; but if it is explained to the mother that fat does not 
mean health, overfeeding may be avoided. This is especially true 
of mixed feeding ; such infants are apt to be overfed and to be over- 
weight, for a mother who has two nursings of the breast will be apt 
to consider this of very little moment and attempt to feed on the 
bottle, as if the infant had nothing from the breast at its disposal. 
The result is that such infants frequently suffer from overflow vom- 
iting. In many cases this overflow vomiting does not seem to dis- 
turb the infant to any appreciable degree. It should be avoided, 
however, for we never can say when such vomiting may become a 
matter of serious moment. 



ARTIFICIAL FEEDING OF INFANTS. 123 

VIII. ARTIFICIAL FEEDING OF INFANTS. 

Artificial feeding of infants is the substitution for the breast milk 
of some one of the foods considered in the previous pages. Although 
attempts have been made to rear infants artificially on asses' or 
goats' milk, the experiment has failed, and cows' milk is univer- 
sally utilized as a substitute for the mother's breast in artificial 
infant-feeding. 

Before cows' milk can be given to the infant as a food it must be 
modified. By this is meant a dilution of the milk, as to its fat, 
proteid, and sugar constituents, so as to make it conform as much 
as possible, in percentages of its constituents at least, to human 
milk. There are two methods now well recognized of modifying 
cows' milk for infant-feeding. One of these methods is the so-called 
laboratory method of infant-feeding. The laboratory method of 
infant-feeding attempts to recombine the fat, proteids, and sugar of 
milk not only in proportions which conform to what is found in 
human milk, but to attempt to find out, by the frequent changing 
of these constituents, what is best adapted to each infant. Botch 
and his school contend that w^hat is good for or adapted to one infant 
may not be suitable for another. In his own words : " What is one 
infant's food may be another's poison." The Botch method of 
infant-feeding has now had a very extensive and thorough trial. Its 
successes and failures will be talked of later on. Suffice it to say 
here that, in practice, if an infant does not thrive on a certain limited 
number of modifications of cows' milk, experience shows that we 
reach a point where our knowledge is no longer definite as to what 
changes may be required in the various formulse in order to make 
the infant thrive. In other words, some infants will not thrive on 
cows' milk, no matter how many changes are made in the percent- 
ages of fat, proteids, and sugars. These are the difficult cases of 
infant- feeding which baffle the most skilful efforts at modifying 
cows' milk. The casein of cows' milk has been from the outset the 
point of attack. The old methods of infant-feeding considered 
simply the dilution of the whole milk two or three times, either 
with simple water or with some decoction of a cereal, either barley 
or arrowroot. In the first month the milk was diluted one in three ; 
in the second month, one in two ; in the third month, two in three, 
etc. These simple methods continued in use until Biedert, in Ger- 
many, and Meigs, in the United States, attempted to proportion the 
casein, fat, and sugar so as to make the mixture approach the com- 
position of human milk. Biedert called his food a cream mixture. 
It was made in the same general way as Meigs' mixture. There 
was a low percentage of proteids, and a fat percentage corresponding 
to what is found in human milk. The proteids in Meigs' mixture 
ranged from 1.2 to 1.5 per cent. In Biedert's mixture the proteids 



124 



ARTIFICIAL FEEDING OF INFANTS. 



existed to the extent of 1 per cent., fat 2 to 2.5 per cent., sugar 4 
per cent. Meigs' mixture contains 3.5 per cent, of fat and 6 per 
cent, of sugar. 

Biedert's Mixture. — Biedert took 50 ounces of milk, or 1.5 litres, 
and allowed it to stand one hour. The cream taken off the top of 
this milk contained 10 per cent, of fat. The amount of cream was 
8 ounces. In other words, the top 8 ounces oif 50 ounces of milk 
was a 10 per cent, top cream. With this he constructed the follow- 
ing formulae. 



Number of 
mixture. 


Cream (10 
per cent.). 


Water. 


Milk-sugar. 


Milk. 


Casein. 


Fat. 


Sugar. 




Litre. 


Litre. 


Grammes. 


Litre. 


Per cent. 


Per cent. 


Per cent. 


I. 


^ 


f 


18 




(= 1.0 


2.5 


5.) 


II. 


1 




18 


tV 


(= 1.4 


2.6 


5.) 


III. 


|. 


1 


18 


i 


( = 1.5 


2.6 


5.) 


IV. 


1 


1 


18 


i 


(= 1.8 


2.8 


5.) 


V. 


i 


1 


18 


f 


(= 2.1 


2.3 


5.) 


VI. 




i 


12 


i 


(^2.8 


2.4 


5.) 



If we compare these formulae with Meigs' mixture, we find that 
Meigs contended that the infant needed through its whole nursing 
period practically one formula. 

Meigs therefore had : 

1. A 16-ounce top milk [7 to 8 per cent, of fat]. 

2. A solution of milk-sugar, 15 per cent. 

3. A solution of lime-water. 

He combined them as follows : 



{i 



3 ounces of top milk. 
8 ounces -{ 3 ounces of sugar solution, 
ounces of lime-water. 



This, according to our present methods, would give approximately 
a mixture of 3 per cent, of fat, 1.3 per cent, of proteids, 6 per cent, 
of sugar, which is also what Meigs strove for, with the exception 
that in some milks, as has been shown, more fat would be obtained 
than that given above, which is calculated from an average milk. 
With some milks Meigs obtained 4.7 per cent, of fat. To be more 
concise, Meigs designed the above method to obtain : 

Water 87.6 1 

Fat 4.7 I 

Casein I-IJ" Meigs' artificial food. 

Sugar 6.2 I 

0.2 J 



ARTIFICIAL FEEDING OF INFANTS. 125 

In what follows we leave the reader to judge how much of Meigs' 
method still remains in the present modes of home modification of 
cows' milk. 

It will be seen from the standpoint of to-day that both these men 
were the real pioneers of percentage feeding. It may be mentioned 
here that the method of Escherich is based on an attempt to calcu- 
late with rough dilutions of milk the amount of albumin necessary 
for the daily maintenance of nutrition. So far as the author knows, 
the Escherich method is very little in vogue in America. 

The other two methods of modifying milk, which calculate the 
gross amount of calories necessary to maintain nutrition for infants, 
are the Huebner-HofPman and the Soxhlet method. They have 
endeavored to construct a chemical mixture with the aid of cows' 
milk which is equal to the raw nutritive calories in mother's milk. 
In both these methods the milk is diluted with an equal amount of 
water. Huebner-Hoffman uses as a diluent a 6 per cent, solution 
of milk, whereas Soxhlet uses a 9 per cent, solution. The addition 
of sugar of milk is intended to take the place of fats, which are de- 
ficient in these mixtures. Sugar of milk, according to Soxhlet, has 
a caloric value equal to that of the fat deficit. 

If it is desirable to feed a great number of infants in a public 
laboratory, I can say from actual experience that these mixtures are 
of the greatest utility, inasmuch as they can be easily prepared, and 
certainly the greater number of infants thrive on them. It is almost 
impossible in a laboratory intended for the use of the poor of a 
great city to give each child a percentage mixture. In other words, 
the feeding en masse is an entirely different problem from the feed- 
ing in private practice. 

Infants from the first to the third month do not thrive as well 
on the Huebner-HofFman and Soxhlet mixtures as they do on scien- 
tific modifications obtainable either in the laboratory or by the home 
method, which will be described. In other words, infants below the 
third month get in these mixtures an excess of proteids and deficiency 
of fat, and digestion is thereby impaired. The Meigs' mixture is 
most applicable to these cases. 

The Rotch Method. — The method of Rotch has as its pivotal point 
the fact that all infants cannot be fed on the same mixture, and, taking 
the composition of human milk as a working basis, each infant should 
be considered as a separate problem in constructing a formula which 
within certain limits would be most suitable to its needs. Rotch 
therefore separates the milk from the cream by means of a separator 
or by gravity, and working with skimmed milk and cream containing 
16 or 20 per cent, of fat and a dilution of milk-sugar, the constit- 
uents of the milk are rearranged. By this method an infant can 
be fed on a mixture of 1.5 per cent, of proteids, 3 per cent, of fat, 
and 6 per cent, of sugar; or 1.5 per cent, of proteids, 2.5 per cent. 



126 ARTIFICIAL FEEDING OF INFANTS. 

of fat, and 6 per cent, of sugar, or any percentage of proteids, fat, 
and sugar that we may desire to give. Rotch also contends that an 
infant which may not thrive on 1.2 per cent, of proteids might do so 
on 1.5 per cent. The proportion of fat may be reduced or in- 
creased as needed in the individual case. In other words, the 
physician should consider his percentage formula in feeding the 
infant, just as he prescribes a certain strength of a drug. 

To obtain these percentages a laboratory is needed, and to-day 
laboratories for supplying these mixtures to be used in the percent- 
age feeding of infants are to be found in large cities. Though 
theoretically this method of reconstructing the milk would seem on 
the surface to be the most rational, it has certain inherent defects 
which Rotch and his pupils are trying to overcome. These defects 
are much the same as those of the older methods. 

1. By simply rearranging the proteids, fat, and sugars we do not 
change the proportionate relationship which the casein or caseinogen 
bears to the lactalbumin and other proteids of the milk. 

2. With the exception of a few limited facts and formulae we 
have no data which, with our present knowledge, will enable us to 
know in every case when to increase or to diminish the proteids and 
also the fats. 

3. The process of separating the cream from the milk by machinery 
destroys the original delicacy of the fat-emulsion in the milk. The 
infant does not assimilate these mixtures in every case as well as 
those which are constructed from milk which has not been manip- 
ulated to the extent that laboratory milk has. 

In order to utilize the Rotch method by means of the laboratory, 
the physician has simply to prescribe the percentages that he re- 
quires on a slip made out for the purpose and furnished by these 
laboratories. It is needless to say that unless a physician is satis- 
fied to follow a routine common to all his cases, instead of trying to 
understand the needs of each infant, he is certain to meet cases 
which even the most accurate modifications of the laboratory will 
not cause to thrive. In other words, the laboratory alone will not 
enable the physician to feed infants successfully. To do this he 
must know not only the percentages required at certain ages from 
constructed formulse, but must study the digestion of each child, its 
movements, try to analyze from the movements whether the proteids 
are digested, or the fats are in excess or in diminished quantity. It 
may be said that in practice the most successful men find that they 
can get along on a very few fixed formulae. An infant which will 
not thrive on these formulae within certain limits will not thrive on 
any percentage modification of cows' milk, no matter how we may 
rearrange the percentages of its ingredients. 

Principles Underlying the Rotch Method of Percentage Feeding. — 
As has been intimated, we must distinguish very carefully between 



ARTIFICIAL FEEDING OF INFANTS. 127 

infants who are quite normal and those suffering from disturbances 
of the gut in feeding them with cows' milk. The healthy infant 
needs but very few changes of formulae throughout its infant life. 

The first fact which we must establish from the birth of the in- 
fant is whether its organs are capable of digesting cows' milk at all. 
If such is the case^ by a careful beginning and modifications of milk 
we can carry the infant along on very few formulae, possibly three 
or four, through its period of infancy. 

Proteid. — The total amount of proteids in the cows'-milk mix- 
tures must be very low for the newborn infant, certainly not to 
exceed 0.5 per cent, during the first week. After this the proteids 
are increased to 1 per cent., and kept at this point until the third 
month, when they are increased to about 1.5 per cent., and we may 
keep them here until the ninth month. For vigorous infants of heavy 
weight we may increase the proteids at the sixth month to 2 per cent. 
I have never found it necessary to go beyond that percentage. 

Fats. — The fats in the first days after birth should be low — 
from 1.5 to 2 per cent. After the second week to the third month 
we may give from 2.5 to 3 or 3.5 per cent, of fat ; rarely more than 
this. The reason for this is, that during this period the infant will 
not digest more fat. Infants who are getting a larger amount of fat 
than the percentage indicated will, as the nurse puts it, frequently 
" spit up " curds between the feedings. All the movements will be 
frequent, soft, and in some cases even of an oily consistence. In 
other words, infants who are taking a greater proportion of fat than 
that indicated will have a mild fat-diarrhoea, which may at any time 
become more severe and give rise to considerable concern. From 
the third month to the termination of infancy the fats may range 
from 3 to 3.5 or even 4 per cent. ; never more than this. 

Sugar. — In modifying milk the sugars are placed in the mix- 
ture at a uniform percentage of 6 per cent. It is rare for us to be 
called upon to alter this percentage to any considerable extent. Too 
much sugar will cause in some cases fermentation in the gut, result- 
ing in the production of gas. The children may thrive for a time 
on an excess of sugar ; but in all these cases, sooner or later, a point 
is reached at which the sugar is no longer tolerated in large percent- 
ages. It is therefore unwise to give a larger percentage of sugar 
than that indicated. 

Salts. — The salts of the cows' milk are scarcely considered in 
percentage modifications. We know very little to-day about the 
fate of the salts in the cows' milk — how much of them are absorbed 
and exactly how much rejected by the infant gut. It has been inti- 
mated in another paragraph that the heating of the milk causes a 
complete loss to the economy of the salts present in cows' milk ; but 
inasmuch as the heating of milk is coming more and more into dis- 
credit, and more pronounced efforts are being made to obtain a pure 



128 



ARTIFICIAL FEEDING OF INFANTS. 



milk which can be administered with as little heating as possible, 
we have still to learn the fate of the salts in sterilized, Pasteurized, 
or raw milk, and the indications for adding equivalents of soluble 
salts to the milk for the feeding of infants. 

A Schedule of Percentages Adapted to Infants of Various Ages. 



Age. 


Proteids. 


Fat. 


Sugar. 


» 

Premature infants 

One to seven days 

Seven to fourteen days 

Fourteen to thirty days ...... 

One to three months 

Three to six months 

Six to nine months 

Nine to twelve months 


Per cent. 
0.33 
0.50 
0.80 
1.00 
1.25 
1.50 

1.50 to 2.00 
3.05 


Per cent. 
1.00 
1.50 
2.50 
3.00 
3.75 

3.00 to 4.00 
3.00 to 4.00 
4.00 


Per cent. 
5 to 6 
5 to 6 
5 to 6 
5 to 6 
5 to 6 
5 to 6 
5 to 6 
5 to 6 



Number of Nursings, with the Necessary Quantity of Milk to 
be Fed to the Infant. — The quantity of milk which should be given 
to the infant at each feeding from birth to the ninth month has been 
variously estimated. In the author's opinion and that of most 
practical men, the capacity of the stomach alone would be a crude 
and most unscientific standard, for this would not, in artificial feed- 
ing at least, follow nature's method with breast-feeding, for from 
birth the amount of milk furnished to the infant by the human 
breast daily does not always accord with the full capacity of the 
infant's stomach. It will be found that the quantity fed to the 
breast-fed infant is much below the stomach capacity if the infant is 
fed at frequent intervals, and, as has been shown in Ahlfeld's baby, 
equal to or even above it if nursed at long intervals. With artificial 
feeding, moreover, we know that there is a great waste in feeding 
infants upon cows' milk, and were an infant fed on exactly the same 
amounts of modified cows' milk as some of the breast-fed infants 
obtain from the breast, it would not increase regularly in weight and 
might even starve. 

The age of the infant, also, is not a guide, for what would be 
a sufficient amount for one infant might not be sufficient for an- 
other, or might be even an excess. In all cases the capacity of 
digestion must be taken into account, and also the development of 
the child. Some vigorous infants will take more food than other 
infants of the same age that are not as well developed physically. 
More rational is the method of arriving at the amount to be given 
at each feeding which takes into consideration not only the capacity 
of the stomach, but the age and the amount of primary food ele- 
ments necessary to maintain nutrition and to increase body-weight 
of the infant at various ages. If we calculate the amount of 



ARTIFICIAL FEEDING OF INFANTS, 129 

albumiD or proteids or fat necessary per kilogramme of the body- 
weight to maintain nutrition, we shall have the more scientific 
method of determining the quantity of milk to be taken daily by 
the infant. This method has been advocated by Huebner and Rubner 
and also Escherich. The difficulty of calculating what is known as 
the calories necessary to the maintenance of nutrition and body- 
weight — and by calories is meant practically the amount of albumin 
or proteids, fat, salts, and Avater mentioned above — is, that the 
student or the physician cannot always have at his disposal a method 
by which these calculations can be made. In other words, they must 
rely on investigations made by others, and understand that the results 
as they are presented to us to-day in infant-feeding are not based on 
actual calculations of the amount of calories necessary to the infant. 
It has been found that the nutrition of artificially fed infants cannot 
be maintained by an amount of proteid of cows' milk equal to that 
taken in the breast milk. In other words, the proteid equivalent 
can be obtained, but other constituents, such as fat, would be at 
fault, as well as the daily quantity of food, were we to depend en- 
tirely upon the caloric method. The figures given to the student 
and physician to-day, therefore, are a combination of what has been 
found empirically to be needed, and what has been verified in the 
chemical laboratory to be absolutely necessary. Let the student 
therefore study the amount of breast milk consumed by the infant in 
the twenty-four hours, and compare these amounts with the amounts 
consumed by the bottle-fed infant in the same period of time. 

Number of Nursings Daily with the Necessary Quantity of 
Each Feeding for the Artificially Fed Infant. — If we now attempt 
to apply the knowledge acquired in the study of the breast-fed infant 
to the artificially fed infant we meet with the following obstacles : 
Cows' milk taken in the same quantities, as has been said, is not as 
completely used up by the gut as breast milk. There is much more 
waste, as has been shown by Knopfelmacher and Camerer. This 
waste is caused chiefly by the failure of the gut to assimilate com- 
pletely the casein and the fat of the cows' milk. The stools, also, 
of bottle-fed infants are more numerous and of greater total bulk 
than those of breast-fed infants. Knopfelmacher has shown that 
the waste of phosphorus of cows' milk is sixteen times as great in the 
gut as the waste of that element in the breast-fed infant. In view 
of the lack of definite knowledge on all these points, the quantities 
of modified cows' milk which should be given at each feeding to the 
infant are still, as has been intimated, only approximate. The 
amount of calories necessary for the maintenance of nutrition and a 
definite increase of the body-weight will be shown elsewhere, and 
the student may compare the tables given with the equivalent calories 
in the total amount of breast milk and cows' milk given to the 
breast-fed or artificially fed infant. He can therefore satisfy him- 

9 



130 



ARTIFICIAL FEEDING OF INFANTS. 



self of this fact that the older authors, and even some of the most 
recent writers, underfeed their infants, if the food which they pre- 
scribe in their monographs and text-books is strictly adhered to in 
quantity and composition ; and such is the fact, for many of these 
infants I found by observation not only to be underweight, but in 
some cases they fail in complete assimilation of their foods. Per- 
centage feeding, therefore, is not as fixed and definite a science as 
the student would be apt to think were he to rely absolutely on the 
statements and formulae of many writers. The student must also 
understand, however, that only a few of these formulae and state- 
ments really epitomize the limit of our knowledge to-day, and future 
investigators must complete that knowledge. 



Table Showing the Number of Feedings and Quantities of Modified 
Milk to be Given to ArtifiGially Fed Infants. 



Age. 



First day 

Second day 

Third day 

Fourth day 

Seventh day 

Second week 

Fourth week or first month 

Two months 

Three months 

Four months 

Five months 

Six months 

Seven and eight months . 
Nine months 



Number of feed- 
ings daily. 



8-10 
8-10 
8-9 
7 or 8 

7 

7 
6 or 7 

6 

6 



Quantity at each 
feeding. 



C.c. 

10 

20 

30 

40 

50 

60 

60 

90 

120 

150 

180 

210 

240 

250 



Oz. 



8^ 



Total to be given 
in 24 hours. 



C.c. 
30 

160 

240 

320 

400 

480 

480 

630-720 21-24 

840 28 
1050 35 
1080-1260 36-42 
1260 42 
1440 48 
1500 50 



Oz. 

1 

5^ 

8 

101 
13i 
16 
16 



The increase in the amount of milk from the seventh to the ninth 
month is not so apparent, since at this period we, as a rule, begin to 
feed cereals in addition to the milk. 

The above figures are not absolute, but only approximate. Some 
infants may require a half-ounce or more than the quantities indicated ; 
others will be satisfied with less nursings. In all these items an 
observant student of the infant will, guided by the observations of the 
nurse of the infant, discover the indications in each case for himself. 



Household Modification of Milk for Infant-feeding". 

The accuracy of laboratory-feeding cannot be denied ; its universal 
success, however, can well be questioned. For this reason a consistent 
attempt has been made to modify milk, as it comes from the dairy, 
in the home of the patient, without unnecessary manipulation. The 



HOUSEHOLD MODIFICATION OF MILK. 131 

accuracy obtaiDed in home modification, it can be said, is as well 
adapted to the feeding of infants as the laboratory percentages. The 
author, whose experience is quite wide in the matter of feeding infants 
by home percentage modification, can say that the home modifica- 
tion of milk for infant-feeding, if carefully carried out, can boast of 
just as brilliant results as the laboratory method. The advantages 
of home modification of cows' milk for infant-feeding may be stated 
briefly as follows : The family and the physician can be independent 
of the modifier at the laboratory. The milk is manipulated as little 
as possible. If the infant does not thrive, we can say as definitely 
as by the laboratory method what is at fault. It has been shown 
that many of the laboratory modifications are no more accurate in 
themselves than those of the home method, and the percentage of 
error is just as great in the laboratory modifications, if carried out 
for a great number of infants, as the home modification. This has 
been shown quite conclusively by Townsend, of Boston. 

The home modification of milk for infant-feeding depends on the 
fact that in large cities, and in places where milk is obtainable from 
the dairy within a reasonable time, the milk can be separated by 
gravity into top milk or cream and skim milk, and this separation 
takes place in certain definite proportions. Meigs, Biedert, and 
Chapin showed that it is possible to construct from top milk definite 
percentage mixtures, inasmuch as the top milk prepared in the 
manner to be described has an average constant percentage of fat, 
proteids, and sugar. Meigs was the first to work out a definite 
percentage mixture from top milk ; Chapin has elaborated this 
idea. 

Top Milk. — If milk fresh from the dairy is placed in a utensil, 
either a quart bottle or some similar vessel of like capacity, it sep- 
arates within four hours after milking into a creamy, supernatant 
fluid and a skim milk. In the supernatant creamy fluid, or top 
milk, we find certain definite percentages of fat. In modifying milk 
in the home, the top layer as it separates from the milk is utilized 
as it is delivered in quart bottles. Chapin has found that if a 
number of milks delivered in the city homes are analyzed, the first 
9 ounces from the top of the quart bottle of milk will contain all 
the way from 12 to 16 per cent, of fat, varying with the richness 
of the milk in fat. 

Twelve Per Cent. Top Milk. — If the original milk contains 4 per 
cent, of fat, the first 9 ounces will be what is known as a 12 per 
cent, top cream. If the milk is a very rich milk containing butter 
fat to the extent of 5 per cent., the top 9 ounces will contain 16 
per cent., approximately, of fi^it. The proteids are quite constant 
in the top milk and are equal to those found in the skimmed milk. 
In other words, in milk rich in butter fats the top milk contains fat 
in proportion to the proteids of 3 to 1. If the milk is poor and 



132 ARTIFICIAL FEEDING OF INFANTS. 

only contains 3 per cent, of butter fat, the first 9 ounces will contain 
generally 9 per cent, of fat, and this milk will contain 3 per cent, of 
proteids, so that the percentage of fat to proteids still remains 3 to 1. 
It may be said at the start that the student would do well not 
to consider the thin milk as existent, for most milk, either in the 
city or throughout the country, contains at least 4 per cent, of 
butter fat. 

Seven Per Cent. Top Milk. — Another top milk to be considered is 
the so-called first 16 ounces taken from a quart of milk. If the 
milk is a rich milk and contains 5 per cent, of butter fat, the first 
16 ounces will contain 9 per cent, of fat. If it is a rich milk and 
contains 4 per cent, of butter fat, the first 16 ounces will contain 7 
or 8 per cent, of fat. The fat in both of these instances is present 
in a proportion of 2 to 1, as compared to the proteids. The student 
would do well to assume in making his modifications that he is deal- 
ing with a rich milk. In this way he will avoid giving mixtures 
which contain too much fat, which element gives the most trouble 
if present in too great quantity. If the student will therefore simply 
consider the top 9 and 16 ounces of rich milk, he will have sufficient 
material for feeding the infant up to the ninth month of infancy. 
The student should therefore try to perfect himself in the methods 
of utilizing top milk in which the fat is present, as compared to the 
proteids, in the proportion of 3 to 1, and a more dilute top milk in 
which the fat is present, as compared to the proteids, in the propor- 
tion of 2 to 1. 

In feeding infants up to the third month it is convenient to use a 
top milk in which the fat is present, as compared to the proteids, in 
the proportion of 3 to 1. In other words, it is best to use the first 
9 ounces of top milk, for by this method we can obtain, as will be 
shown by the tables, a smaller percentage of proteids and the 
requisite percentage of fat indicated in the earlier periods of infancy. 
From the third to the sixth month it is advisable to use a top milk 
in which the fat is present, as compared to the proteids, in the pro- 
portion of 2 to 1, for in this way we can obtain a larger percentage 
of proteids and more fat from one bottle of milk than we could if 
we use a smaller amount of richer top milk in which the fat is 
present, as compared to the proteids, in the proportion of 3 to 1, 
for in the latter case we shall be compelled to use 2 bottles of milk. 
This can more readily be understood by reading the subjoined tables 
indicating the percentages at the various ages. 

Chapin, for the purpose of obtaining the top milk, has devised a 
small dipper. The use of the dipper is convenient but not neces- 
sarily essential. If the top milk is poured off carefully, equal accu- 
racy is obtainable without the use of the dipper. 



THE METHOD OF CALCULATING PERCENTAGES. 133 

Top Milk Made at Home. 

Clean Milk. — In cities milk is delivered in quart bottles, and in 
many places in the country this is also the case. But if the prac- 
titioner is living in a district where bottled milk is not sold or not 
obtainable, it is quite necessary that he should understand that there 
is no mystery about bottled milk. Any milk obtained shortly after 
milking and placed in a wide-necked bottle or utensil with a capacity 
of one quart will separate the top milk, or set, as it is called, in 
the manner previously described under the heading of Top Milk. 
This setting process takes place within four hours after the milk is 
placed in the utensil, so that, if the practitioner has not access to 
bottled milk, he can be just as accurate as the city physician if he will 
obtain an ordinary quart utensil, such as a pitcher, and place the 
milk in the same as soon after the milking as possible, setting it aside 
for four to six hours, and then proceeding according to directions given. 
Such milk will show the separation into the skim milk and creamy 
layer, as described elsewhere. There should be no visible dirt or dark 
specks in the bottom of the bottle, for such milk is unwholesome and 
should not be given to the infant. The milk on opening the bottles 
should have no peculiar odor, for such milk, no matter how carefully 
modified, will be rejected by the infant. If mixed with equal portions 
of 70 per cent, alcohol, milk when heated in a test-tube should not 
curdle. In other words, we should begin with a good, fresh, clean 
milk. 

The Home Preparation or Modification of Milk for 
Infant-feeding. 

In what follows it must not be forgotten that the formulae and 
statements are directed toward the management of distinctly nor- 
mal cases. If an infant does not thrive on these formulae, the 
physician must be thrown on his experience and deftness in order 
so to modify the formulae that digestion will be accomplished with- 
out difficulty. We will consider the percentage modification of cows^ 
milk in the household, presupposing that there are no difficulties in 
the way of the infant's complete assimilation. 

The Method of Calculating Percentages. 

We know that in the first 9 ounces of top milk the ratio of fat to 
proteids is as 3 to 1, and in calculating any percentages, whether we 
fix on the proteids or on the fats as a method of calculation makes 
very little difference, provided we remember this proportion. For 
example : If we calculate on a formula containing 3 per cent, of fat, 
and we desire to construct this formula with the first 9 ounces of top 
milk, the proteids in that formula will be 1 per cent. If we wish to 



134 ABTIFICIAL FEEDING OF INFANTS. 

give 0.25 per cent, proteids from the first 9 ounces of top milk, the fat 
must necessarily exist in a percentage of 0.75. It is well, therefore, for 
the practitioner simply to fix in his mind what percentage of one or 
the other ingredient he desires to give to the infant, calculate upon 
that, and the fat or proteid will exist in that formula in the ratio 
indicated. The author, for convenience, fixes the amount of pro- 
teid which he wishes in his mixture, multiplies that by 3, to obtain 
the percentage of fat that would exist in that mixture, and proceeds 
in the following way : An infant at birth, for example, will receive 
0.5 per cent, of proteids, its fats would be 1.5 per cent., if con- 
structed from the first 9 ounces of top milk. 

Let us suppose, for example, that a 12 per cent, top milk is to be 
used, and that the total amount to be given in twenty-four hours is 
8 ounces. We wish to reduce the percentage to 1.5. The question 
involved is, ^^How much of the 12 per cent, top milk must be used 
to make a 1.5 per cent. 8-ounce mixture?^' The following math- 
ematical statement simplifies the process : 

If of a 12 per cent, top milk you would use 8 ounces in twenty- 
four hours, to make a 1 per cent, top milk you would use -^ of 8, 
equal f ounces. To make a 1.5 per cent, top milk you would use 
1.5 times f, equal 1 ounce. 

One ounce, then, of a 12 per cent, top milk, diluted 7 times, will 
give an 8-ounce 1.5 per cent, mixture. 

How to Work Out the Above Percentages of Fat, Proteids, and 
Sugar. — Problem 1. — Let the physician take, for example, a prema- 
ture infant. By referring to the schedules it is seen that such an infant 
should have 10 or 12 feedings in the twenty -four hours. The most 
assimilable mixture should have a strength of 0.33 per cent, proteids, 
1 per cent, of fat, and 5 or 6 per cent, of sugar. Such an infant 
should have 12 feedings, each J ounce, making a total of 6 ounces 
for the twenty-four hours. If a 12 per cent, top milk is utilized, 
inasmuch as the fat-percentage of our mixture is 1 and that of our 
top milk is 12, the total quantity in the twenty-four hours being 6 
ounces, we need -^ of 6, equal J ounce of this 12 per cent, top milk, 
which must be diluted by 5 J ounces of water or barley-water, as the 
case requires, in order to obtain a mixture of 6 ounces containing 
1 per cent, of fat. 

In order to get the requisite percentage of sugar of milk which, 
when mingled with the diluent and the J ounce of top milk, will 
approximate 5 per cent., 2 teaspoonfuls of sugar of milk should be 
dissolved in the diluent before adding the top milk. 

Problem. 2. — The infant is one month old. Such an infant 
would assimilate best a mixture approximating 1 per cent, of pro- 
teids, 3 per cent, of fat, and 5 per cent, of sugar. It would need 
10 feedings in the twenty-four hours, each containing 2 J ounces, 
making a total quantity of 25 ounces. If the 9-ounce top milk is 



THE METHOD OF CALCULATING PERCENTAGES. 135 

used (12 per cent, of fat) we would proceed as follows : The per- 
centage of fat desired being 3, and the total daily quantity being 25 
ounces, we would have to take y^ of 25, equal to 6 J ounces of 12 
per cent, top milk, with 18f ounces of the diluent, which should 
contain 6 per cent, of milk-sugar, or 7 teaspoonfuls. 

Problem 3. — The infant is four months old, and it is desirable 
to construct its formula from the 16-ounce top milk (7 per cent, 
fat), ratio of fats to proteids 2 to 1. The percentages most adapted 
at this age would be 3 of fat, 1.5 of proteids, and 5 of sugar of 
milk. This infant should have 8 feedings in the twenty-four 
hours, each containing 5 ounces, a total of 40 ounces of food in 
the twenty-four hours. The percentage of fat being 3, that of 
the top milk 7, and the total amount of food being 40 ounces, there 
would be needed ^ of 40, equal to 17 ounces of top milk, with 23 
ounces of the diluent, to which is added 6 per cent, of milk-sugar, 
or 9 teaspoonfuls. 

For the above formula it will be necessary to use 2 bottles of milk, 
taking 16 ounces off each, mixing them together, and of these 32 
ounces to utilize 17. 

Problem 4. — The infant is six months of age, and would 
need 7 feedings, of 7 ounces each, making a total of 49 ounces for 
the twenty-four hours. The formula most adapted in this case would 
be 3 per cent, of fat, 1.5 per cent, of proteids, and 5 per cent, of 
sugar of milk, utilizing the top 16 ounces of a bottle of milk, the 
percentage of fat in the formula being 3, that of the top milk 7, and 
the total amount of the food being 49 ounces, there would be needed 
^ of 49, equal to 21 ounces of top milk ; 28 ounces of the diluent 
will be necessary, containing 5 per cent, of milk-sugar, or 9 tea- 
spoonfuls. 

It will be necessary in this case, also, to utilize two quart bottles 
of milk to obtain 21 ounces of 16-ounce or 7 per cent, top milk. 
That is, 32 ounces of this top milk are obtained, and of these 21 
ounces only are utilized. 

Problem 5. — The infant is nine months of age. In this 
case 6 feedings will be given in the twenty-four hours, each contain- 
ing 8 ounces, making a total of 48 ounces. The formula most 
adapted to this age would be 4 per cent, of fat, 2 per cent, of pro- 
teids, and 5 per cent, of milk-sugar. The percentage of fat being 4 
in the formula, that of the top milk 7, and the total quantity of 
food for the twenty-four hours being 48 ounces, the physician would 
need j- of 48, equal to 24 ounces of 7 per cent, or 16-ounce top 
milk, 24 ounces of the diluent, and enough sugar of milk to make a 
5 per cent, solution. 

Problem 6. — An infant six months of age, for therapeutical 
reasons, is to be put on a formula containing 1.5 per cent, of fat, 
0.5 per cent, of proteids, and 5 per cent, of sugar. Here the per- 



136 ARTIFICIAL FEEDING OF INFANTS. 

centage of fats to the proteids is as 3 to 1, therefore it will be con- 
venient to use the top milk containing 10 to 12 per cent, of fat and 
3.5 per cent, of proteids. It is desired to give the infant 7 feedings 
of 7 ounces each, making a total of 49 ounces. The percentage of 
fat being 1.5 in the formula, and that of the top milk being 12, 
the total quantity for the twenty-four hours being 49 ounces, 

15 
the physician would need — '- — of 49, equal to 6|- ounces of top milk, 

42|- ounces of the diluent. In order to get a 5 per cent, solution 
of the milk-sugar there would be needed in this case 5 per cent, of 
42 ounces, equal to 18 teaspoonfuls of the milk-sugar. 

It frequently happens with infants above three months of age 
taking a modification of the 16-ounce top milk that constipation 
will set in, and we wish to increase the fats in order that the move- 
ments may be less constipated. In order to do this we must obtain 
a top milk which is richer in fat than the top milk we are giving. 
To illustrate : The infant who is taking a third dilution of the 
16-ounce top milk will be taking approximately 2.5 per cent, of 
fat, 1.2 to 1.5 per cent, of proteids. If we wish to increase the fats 
to 4 or 3.5 per cent, and retain the proteids we are administering to 
the infant, it will be impossible to do this with the 16-ounce top 
milk, for any dilution of this milk will vary the proteids. We are 
therefore compelled to resort to the utilization for such an infant of 
the 9-ounce top milk, which contains an average of 10 to 12 per 
cent, of fat. By diluting this one- third we would get about 3.5 to 
4 per cent, of fat and still retain the same percentage of proteids as 
in our original mixture. 

An infant four months of age, taking eight bottles, 5 ounces each, 
would need 40 ounces for its daily mixture. We would therefore 
be compelled to use, in order to obtain the 9-ounce top milk, 2 
quarts of milk, from each of which 9 ounces would be taken, making 
18 ounces of top milk. This, after being thoroughly mixed, would 
be utilized to the extent of 13 ounces for our mixture, giving 27 
ounces of the diluent, whatever that may be, we would have a 
formula of 3.5 per cent, fat, 1.3 to 1.5 per cent, proteids. 

Formuloe constructed with top d-ounce milky having an average 
composition of 12 per cent, fat, 3.5 per cent, proteids, 4 per cent, 
sugar. Possible combinations. 

Fat. Proteid. Sugar. 

0.33 per cent. 5 per cent. 



1.00 


3er cent. 


1.50 




2.00 




2.50 




3.00 




3.50 




4.00 




4.50 


<( 



0.50 

0.66 
0.83 
1.00 
1.20 
1.33 
1.50 



THE METHOD OF CALCULATING PEBCENTAGES. 137 

Formulce constructed with top IQ-ounce milk, having an average 
composition of 7 per cent, fat, 3.5 per cent, proteids, 4 per cent, sugar. 
Fats to pi'oteids 2 to 1. Possible combinations. 

Fat. Proteid. Sugar. 

1.00 per cent. 0.50 per cent. 5 per cent. 

1.50 " 0.75 '' 5 " 

2.00 " 1.00 " 5 

2.50 " 1.25 " 5 

3.00 " 1.50 " 5 '' 

3.50 " 1.75 " 5 '' 

4.00 " 2.00 " 5 " 

Whole milk having an average composition of 4 per cent, fat, 3.5 
per cent, proteids, 4 per cent, sugar. Fats to proteids 8 to 7. Pos- 
sible combinations. 



Fat. 


Proteid. 


Sugar. 


1.00 per cent. 


0.85 per cent. 


5 per cent. 


1.50 " 


1.32 


u 


5 


2.00 " 


1.60 




5 " 


2.50 " 


2.15 




5 


3.00 " 


2.60 




5 


3.50 " 


3.00 




5 


4.00 " 


3.50 




5 " 



It should be understood that the percentages of fats given in 
these tables can only be obtained with approximate accuracy, for 
there is no milk which will yield an absolute fixed percentage of fat 
in the top milk obtained by gravity, without variation, from day to 
day. The proteids, however, are more constant in percentage ; but 
even here in modification we can only obtain approximate accuracy. 
Though these tables contain 8 modifications each, some of them 
differing but ^ of 1 per cent, either in the fats or the proteids, such 
minutise are not really needed or even possible in practice. It will 
be found best to master 3 or 4 modifications of top milk, constructed 
either from the 9-ounce top milk or the 16-ounce top milk, and 
utilize these in general practice. For example : The infant who is 
taking 1 per cent, of fat and 1.33 per cent, of proteids may do just 
as well on 1.2 per cent, of fat and 1.50 per cent, of proteids. For 
all practical purposes, therefore, formulae which contain 1.5, 2.5, 
and 3.5 per cent, of fat will be as available in practice as formulae 
containing 1, 2, and 3 per cent, of fat. 

Referring to the proteid percentages, it will be seen that certain 
of them are in heavy-faced type. Both in the laboratory and at home 
it is impossible to obtain an accuracy which will assure the physician 
that he is administering to his patient 0.66 and not 0.5 per cent, 
of proteids, or some intermediate figure ; nor can he be certain that 
his mixture, even if prepared at the laboratory, contains 1.23 or 
1.33 per cent, of proteids, rather than some slightly higher or lower 
figure. The reason for this is that the proteids of cows' milk, like 
the fats, must vary from day to day, and thus no absolute fixed 



138 ARTIFICIAL FEEDING OF INFANTS. 

average percentage of proteids can be counted on. Konig, in an 
analysis of several hundreds of milks obtained from a number of 
herds of cows, shows that the proteid percentages in milk vary, not 
only at different seasons of the year, but at times of the day, and also 
with different kinds of fodder. It is therefore illogical to attempt the 
working out of minutiae of percentages varying from 0.2 to 0.3, 
when the original milk has not a fixed average percentage. To 
obtain accuracy within the difference between 0.2 to 0.3 per cent, 
would necessitate a chemical analysis of the milk before each modifi- 
cation is made, a manifestly impracticable procedure, especially as 
regards the proteids in the milk. The author has gone into these 
matters to show that the elaborate tables given by some enthusiasts are, 
on careful analysis, impracticable. It is well, therefore, for the physi- 
cian to feel assured that with the proteids, as with the fats, approxi- 
mate formulae with averages of 0.25, 0.5, 1, 1.5, 2, and 2.5 per cent, 
of proteids are as effective in practice as minute fractional percentages, 
if such were attainable. In practice, assimilation cannot be reduced 
to that delicate percentage accuracy insisted on by some authors. 

Too High Fat-percentages and Their Remedy. 

If Problem 4 is studied it will be seen that 2 bottles of milk 
must be utilized in order to obtain the requisite 21 ounces of top 
milk, and if this is so for the sixth month, more of this top milk 
will be required for the seventh and eighth months. Some infants 
will not thrive on such a large amount of fat. In the summer 
especially they will spit up, and have several loose movements daily. 
In the face of such difficulties I follow the plan of using only 1 
bottle of milk ; and, if after the fifth month (Problem 3) more than 
16 ounces of top milk are required, I take these off the top of the 
bottle, adding the rest as diluent. Thus, at the sixth month, 21 
ounces off the top of a quart of milk to 28 ounces of diluent. At 
the seventh month, 23 ounces off the top of a quart of milk to the 
required amount of diluent. At the eighth month, 25 ounces off 
the top of a quart of milk to the required amount of diluent. The 
amount of diluent is calculated as in the former tables. 

By this method of simply increasing the amount of milk taken 
off the top of one quart of milk after the sixth month, we arrive at a 
point (the tenth or eleventh month) when the infant is taking a 
full quart of milk with diluent daily. This method, which is ex- 
ceedingly simple, and which in summer particularly does away with 
the danger of excess of fats, has served me well. 

If this method is pursued, the strict calculation of percentages of 
fats and proteids is necessarily abandoned. 

Problem 7. — Let us suppose that for certain reasons top milk 
cannot be obtained, or the milk obtainable is whole milk and the 



TOO HIGH FAT-PERCENTAGES AND THEIR REMEDY. 139 

people are not sufficiently intelligent to construct top-milk mixtures. 
In the table of possible combinations with whole milk there is a 
most available formula : 

Two per cent, of fat ; 1.6 per cent, of proteids. Whole milk having a strength 
of 4 per cent, of fat. 

7 feedings are needed. 

7 ounces each. 

49 ounces in the whole mess. 

Percentage of fat needed, 2, divided by 4 per cent, in the whole 
milk will result as follows : 

2 X 49 = / ^'^ ounces of milk, 

■^ \ 25 ounces of diluent. 

Problem 8. — Taking the same infant with the same 49-ounce 
mixture to construct the formula : 

Three per cent, of fat ; 2.6 per cent, of proteids. We would need : 

3 X 49 = ' '^'' ouJ^ces of milk, 

^ \ 12 ounces of diluent. 

Diluent. — Very little has been said thus far as to diluents in 
modifying cows' milk. The principal function of diluents is to 
dilute or cut up the casein of the milk, or caseinogen, and at the 
same time dilute the fat to such a degree as to make both these ingre- 
dients more digestible in the infant stomach. As diluents used in 
modifying cows' milk, a solution of milk-sugar of definite strength, 
barley-gruel, or whey is used. 

Solution of milk-sugar should be 5 or 6 per cent, strength. Milk- 
sugar chemically pure is sold in the shops as such, and it is dissolved 
in water which has been filtered and boiled or in distilled water. 

As to barley-water, the preparation of which is detailed in full 
elsewhere, it should be remembered that the milk-sugar is dissolved 
in the barley-water while it is being boiled, as in this way there is 
no residue. 

Reaction. — Lime-water is added to all milk mixtures in order 
not only to make them more alkaline, but to aid, as has been shown, 
in the digestion of the casein by delaying coagulation of casein in the 
stomach and favoring the passage of the milk or stomach contents into 
the intestine. The food should contain, according to Meigs and Rotch, 
from one-twentieth to one-twenty-fifth of its bulk of lime-water. 

Lime-water is made by adding about an ounce of unslacked lime 
to half a gallon of boiled or distilled water, shaking well, and then 
allowing it to stand until the supernatant liquid is clear. It is then 
ready for use. 

Lime-water is best added to the food just before giving to the 
infant. Thus, to an 8-ounce mixture are added 3 teaspoonfuls of 
lime-water. I generally advise the omission of the lime-water after 
the sixth month of infancy. 



140 



ARTIFICIAL FEEDING OF INFANTS. 























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WHEN IS A BOTTLE-FED INFANT THRIVING? 141 

When is a Bottle-fed Infant Thriving? 

It may be said that a bottle-fed infant is thriving if it in- 
creases regularly in weight, wakes up betimes to nurse the bottle, 
does not suffer from colic, and has movements of uniform consist- 
ence and color. It should not '' spit up,'' as it is said, to an inordi- 
nate degree. There should be no rejection of food after the bottle 
has been given, thus showing that the quantity has been accurately 
gauged. The color of the infant should be good. The young infant 
should sleep most of the time, except when nursing or engaged in 
play. Older infants should have a happy, contented expression of 
the face. 

We do not consider an infant with a very large deposit of fat as 
necessarily a healthy one. On the other hand, another of exactly 
the average weight may be much healthier than the infant who is 
overweight. Thus, the physician will have to draw conclusions 
from various data of color, weight, development, and well-being of 
the child as to whether it is thriving on the food mixture. 

Physicians should not be afraid to leave well enough alone with 
the artificially fed infant, and, if the gain during some weeks is not 
up to the standard, should not be discouraged, in view of the fact 
that the succeeding week may show the average gain. Bottle-fed 
infants gain very irregularly ; sometimes for a week may appear to 
have gained but very little, an ounce or two. The succeeding week 
may show a marked recuperation and gain in weight above the 
average. 

The physician imbued with the principles of percentage feeding 
also should not be too hasty to change percentages, but should en- 
deavor to content himself with a minimum number of changes. In 
this way the parents of the infant will be impressed with the fact 
that the artificially fed infant is not taking, even at the best, a per- 
fect food, but only one which must make up the deficiencies caused 
by the lack of the mother's milk. 

Among the disturbances from w^hich apparently normal infants 
suifer, and by this we refer to infants who are thriving, are, first, 
constipation. The physician will see an infant on one mixture 
have two movements daily, perfect in color and consistence ; whereas 
another infant on the same mixture will be inordinately constipated, 
and movements hard, having the form and consistence of scybalse. 
He will thus learn to account for this constipation on various 
grounds. A certain percentage of newborn infants are apt to be 
constipated, and this constipation is due to an inherent inertia of the 
gut, and also a lack of secretion of the normal lubricating fluids of 
the gut. In these cases also we may find a tendency to constipation 
inherited from the mother. 

Given an infant with constipation, there are various modes of ren- 



142 ARTIFICIAL FEEDING OF INFANTS. 

dering this symptom a matter of less care to the physician, as well as 
to those in charge of the infant. If the food is heated, it is well to 
omit this process or to reduce the heating to the minimum. We 
should endeavor not to give constipated infants sterilized food ; but 
rather, in the winter and fall, Pasteurized or raw food. By food we 
mean milk mixtures. In some cases it is necessary to increase the 
amount of fat in the mixture, and in this place we should caution 
the physician to go very slowly in increasing the fats for the pur- 
pose of overcoming the constipation. If the fats are increased we 
should never, especially with the newborn or yoiiug infant, give 
more than 3 to 4 per cent, of fat. In many cases 4 per cent, of 
fat will be followed by other symptoms fully as annoying as the 
constipation which the increase of fat was intended to remedy. I 
refer to the so-called spitting or rejection of part of the food after 
nursing. This consists in the bringing up of a number of curds 
in the intervals between feedings. These curds, as a rule, have 
a sour odor and are accompanied by eructations of gas. In such 
cases it is best to reduce the amount of fat, for in very young 
infants an irritation of the stomach to any marked degree, as evi- 
denced by the rejection of a part of the food in the spitting of curds, 
may result in serious vomiting, a symptom much more to be feared 
than the constipation. However, in the administration of top milk 
we very often find, especially with the newborn (and by newborn I 
refer to infants below three months of age), that a fourth dilution 
of top milk replaced by a third dilution will often remedy the con- 
stipation. Fat-diarrhoea caused by too great a percentage of fat will 
be taken up later. 

Spitting. — Spitting, or rejection of part of the food after nursing 
to any extent, may become an annoying symptom, and the physi- 
cian should try his best to remedy it, although the infant may 
apparently be thriving. A breast-fed infant may spit to quite a 
degree and not cause us any uneasiness ; but it is otherwise with an 
artificially fed infant. Such a condition may lead to serious enteric 
disturbances, necessitating a suspension of the food entirely ; or the 
spitting may be due in some cases to an excess of fat, and we should 
try with such infants, even though thriving, to reduce the fat gradu- 
ally until we arrive at a point at which the spitting is less evident, 
at the same time retaining the percentage of proteids in the mixture. 

Colic. — Bottle-fed infants who are apparently thriving and at times 
quite contented will have one or two attacks of colic in the twenty- 
four hours. In a breast-fed infant we may have a number of colicky 
attacks. The breast-fed child may thrive, the movements may not 
show much change from the normal, and the physician in these cases 
is not disturbed ; on the other hand, in an artificially fed infant an 
excessive degree of colic is a cause of uneasiness, not only to the 
family, but to the physician, for it indicates that the digestion of 



WHEN IS A BOTTLE-FED INFANT THRIVING? 143 

the proteids in the mixture does not proceed along physiological 
lines. It has been stated that one or two attacks of colic daily are 
not inconsistent with perfect health in the infant, if the movements 
are of normal consistence and color. On the other hand, any excess 
of colic, combined with a disturbance of the consistence and color 
of the movements, the appearance of curd particles or white curds 
in the movements, or a yellow movement containing too much fluid, 
mixed with white curds, is a signal for a change in the percentages 
of the mixture. In most of these cases the proteids are at fault, 
and they must be reduced. We should not, however, reduce them 
to too low a figure. An infant one month of age can normally 
digest 0.8 to 1 per cent, of proteids. An infant three months of 
age may digest 1 to 1.5 per cent, of proteids ; an infant six months of 
age may digest normally 1.5 to 2 per cent, of proteids. Other infants 
will find it difficult to digest, even at the sixth month, 1.5 per cent, 
of proteids, and will have less colic and the movements will be more 
consistent and normal in color on 1 per cent, of proteids. Less 
than 1 per cent, of proteids for an infant from three to six months 
of age will result in a diminished gain in the weight of that infant, 
although the infant may be thoroughly comfortable. On the other 
hand, some infants at the age of six to nine months may digest 2 
per cent, of proteids without the least discomfort, so that working 
between these limits the physician will have to find out the amount of 
proteids that can be completely digested by the infimt, always bear- 
ing in mind never to allow the proteids to reach too low a percent- 
age, else not only diminished gain in weight will result, but also 
other disturbances of nutrition which we wish to avoid. 

Fat-diarrhoea. — The physician, while increasing the proportion of 
fat in his mixture, the infant thriving at the same time, will find that 
the movements will at times become fluid, though yellow in color ; 
and at other times will be more consistent and of the same color. 
With some infants the movements will become of an oily consistence. 
In such extreme cases there will also be uneasiness with the move- 
ments, and colicky attacks. Movements which are normal in color, 
contain no curds, whose consistence is of an oily character, indicate 
that the fats are in excess of the necessary quantity. Such infants 
may even gain in weight on this excessive amount of fat. The food 
should be suspended in these cases for a few hours, and the mixture 
administered with a diminished amount of fat. Such infants will 
do well on low fat-percentages ; whereas other infants of the same 
age will take more fat and still give no evidences of fat-diarrhoea. 

Greenish Movements. — Bottle-fed infants, apparently thriving, 
will have at times movements which contain green residue and white 
curds, and this will be followed by a movement which is perfectly 
normal in color and consistence. This may be repeated at intervals 
of a week, and I am accustomed to lay no stress on such an occur- 



144 ARTIFICIAL FEEDING OF INFANTS. 

rence. On the other hand, if such green movements occur frequently 
and are accompanied by colicky pains, it indicates that the milk is not 
digested and that the proteids are at fault. Such infants can scarcely 
be included in the normal category ; they are simply mentioned here, 
and the subject will be taken up in another section. 

Disturbances in the Bottle-fed Infant which are on the Bound- 
ary Line between the Normal and the Abnormal. 

(1) Vomiting. — Some mothers will tell the physician that the child 
vomits a certain amount of its food once or twice daily and does not 
seem to be very much disturbed by it. If such an infant increases 
in weight, looks well, and has movements of normal consistence 
there is very little indication for our interference, except, perhaps, 
to reduce slightly the amount of food administered at each nursing. 
The cases, however, which puzzle the physician are those which 
vomit 2 or 3 times daily, and which do not increase in weight in a 
physiological ratio. Such infants increase slightly in weight at first, 
and after a time cease to increase. We have then to deal with an 
abnormal condition. 

(2) Too Low a Percentage of Proteids. — Stationary Weight. 
— It has been mentioned that the physician should be cautious not 
to reduce the percentage of proteids beyond a certain limit. If he 
does, the child will not only fail to increase in weight, but the 
development of the child will be below the normal, and we may even 
incur the danger of scurvy, pronounced rachitis, and other evidences 
of disturbed nutrition. 

(3) Too low a percentage of fats will also result in disturbed 
nutrition to the infant. Constipation is one of the results of too low 
a percentage of fat. By this w'e refer to a percentage of 1.5 of fat 
for an infant five months of age. If such a percentage of fat is 
continued for two or three months, the infant will cease to increase 
in weight and will develop those disturbances of nutrition already 
mentioned. 

(4) Assimilation of the Food Without Increase in Weight. — 
It is not infrequent, especially in the newborn, to find infants who 
completely assimilate the mixture we administer to them. They 
sleep well, are not disturbed by colic, the movements may be consti- 
pated or of normal consistence and color, and still the infant fails 
to increase in weight. These are the baffling cases. An increase in 
the percentages for the newborn infant, or in the quantity of the 
mixture, can be made wdthin certain limits. If we overstep the 
bounds, the mixture will disagree with the infant and cause symptoms 
which will necessitate a temporary suspension of the food. 



WHEY METHOD OF MODIFICATION OF COWS' MILK. 145 

When Shall the Food be Peptonized? 

It has been mentioned elsewhere by the author that in pepton- 
izing the food he makes use of only one method — the cold method — 
for the reason that most infants will not object to the taste of the 
food when this method is employed. The cases in which an 
attempt should be made to peptonize the food are as follows : The 
newborn infant is placed upon a percentage mixture. It suffers 
from constant colic, sleeps very little, has movements which are 
green, mixed with curds ; on the whole the iniant remains stationary 
in weight or the increase is very slight. In these cases most satis- 
factory results are sometimes obtained by peptonizing the food in 
the following way : Just before the food is administered a third or a 
quarter of a so-called peptonizing tube is added to the milk ; it is 
well shaken and heated for two minutes. With this exposure to 
warmth there is very little development of the bitter taste in the 
milk. It is then given to the infant. It is surprising to see what 
an immediate change occurs in the general condition of the infant. 
The child will sleep, the pain and colicky attacks disappear, the 
movements become yellow in color and normal in consistence ; the 
increase of weight will begin and continue along physiological lines. 
The physician must not expect, however, that this result will follow 
in every case, or that this method of preparing the food excludes 
every attempt to attain success by varying the percentages of pro- 
teids and fats in the milk. It is to be supposed that before any 
attempt is made at peptonizing the mixture the physician has made 
every effort to find the correct proportions for his particular patient, 
and having satisfied himself that the percentages are correct and that 
there is a difficulty in the digestion of the proteids, he may proceed 
to peptonize the milk, but not under any other conditions. 

Whey Method of Modification of Cows' Milk. 

This method is really very old. In Routh's ^^Infant-feeding" 
we have the whey method, similar to what is practised to-day, de- 
scribed by Mr. Lobb. This gentlemen, in a brochure on hygiene, 
read before the Harveian Society, gave the details of preparing a 
" compound resembling human milk," and this mode of modification 
of cows' milk as devised by Professor Falkland. Recently the 
method has been taken up by Vigier, and elaborated by Monti, of 
Vienna, in 1897. Rotch has advocated this method of diluting 
milk for feeding infants with difficult digestion. 

Whey has a composition, according to Konig, of — 

Proteid 0.8 per cent. 

Fat 0.2 " 

Sugar . 4.7 

Lactic acid 0.3 " 

Salts 0,6 '* 

10 



146 ARTIFICIAL FEEDING OF INFANTS, 

The proteid contained in whey includes the lactalbumin of the milk 
and lactoprotein. The salts are potassium sodium, lime, and mag- 
nesium, with iron in combination with chlorine, phosphorus, and sul- 
phuric acid. 

Whey is made by adding 1 part of rennet to 200 parts of milk 
at a temperature of 35° to 40° C. (95°-104° F.), or a tablespoon- 
ful of the rennet sold in the shops may be added, roughly speaking, 
to a quart of milk, allowed to stand, mixing thoroughly until the 
milk separates into a liquid and a curd portion. The curd is then 
broken up thoroughly and the whole is strained through cheese- 
cloth. About 20 ounces of whey may be thus obtained from a 
quart of milk. The rennin of the rennet is still existent in the 
whey, and must be destroyed before the whey can be mixed either 
with milk or cream for the purpose of modification. In order to 
do this the whey must be heated to the temperature of 165° F., at 
least — that is, Pasteurized — for thirty minutes. Older authors advo- 
cated bringing the whey to a boil. Whey, as such, without the 
addition of cream or milk, is exceedingly useful in feeding infants 
who are suffering from enteric catarrh. It contains, as is seen, the 
liquid proteid substances of the milk, with salts and water. An 
infant can be kept on such a diet for several days without the 
danger of being starved. It has certain advantages over albumin- 
water, which will be described later. It is acid in reaction, and 
may be sweetened with sugar if the children object to taking it. 

The principle of its introduction into infant-feeding, combined 
with certain percentages of cream, is founded on the fact that, when 
we modify cream or milk to make it conform to the formula as 
found in human milk, we are still dealing with a casein which is 
not present in proportion to the lactalbumin as it is in human milk. 
By thus separating the liquid proteids from the casein and recom- 
bining them this disparity of percentage is overcome. 

The proportion, as has been stated before, of the casein or case- 
inogen to the remaining proteids of cows' milk — the lactalbumin 
and lactoglobulin — is five-sixths of casein to one-sixth of lactalbu- 
min and lactoglobulin, as compared to human milk, which contains 
two-sixths of caseinogen and four-sixths of lactalbumin and lacto- 
globulin. In the whey we obtain all the absorbable proteids ; and 
if we use cream, which is highly concentrated, for fat-proportions 
and skim milk to obtain the caseinogen, we can make a mixture 
which both relatively and actually contains the same proportions of 
caseinogen, lactalbumin, and lactoglobulin as human milk. It must 
be said at the start, however, that the preparation of milk modified 
by the whey method is carried out with the greatest difficulty at 
home ; and even when constructed at the laboratory the method has 
not yet been perfected to such an extent as to be entirely devoid of 
objection. It very frequently happens that unless the whey is thor- 



WHEN PHYSICIAN RESORTS TO INFANT FOODS. 147 

oughly and most carefully Pasteurized, the modified milk curdles 
when heated. It is very difficult thus to prepare the whey mixture, 
although, theoretically speaking, it seems to be the ideal method. It 
has not come into vogue for the reason that the physicians have not 
yet accustomed themselves to the theory of preparing these solutions. 
It is also found that the manipulation to which the milk is subjected 
is open to the same objections that ordinarily obtain with modified 
milk as prepared at the laboratory. Children, for some reason not 
yet explained, do not thrive as well on these carefully prepared 
mixtures as they do on mixtures prepared in the ordinary way. 
This does not at all invalidate the fact that the method may be so 
perfected that a certain class of cases may be fed by this method. 
White and Ladd have reduced casein in these mixtures so that, 
with concentrated cream, skim milk, and whey, they obtain mixtures 
in which caseinogen and casein, as stated, bear the same proportions 
relatively to the lactalbumin and lactoglobulin as it does in the 
human milk; that is, with a total proteid percentage of 1.25, two- 
thirds are whey proteids and one-third caseinogen. 

The following table shows a few of the combinations of caseinogen 
and lactalbumin obtainable from the laboratory : 



Fat. 


Caseinogen. 


Lactalbumin. 


Sugar. 


1.00 per cent. 


0.25 per cent. 


0.25 per cent. 


4 to 7 per cent. 


1.50 


0.25 " 


0.75 " 


4 to 7 " 


2.00 


0.50 " 


0.75 " 


4 to 7 " 


2.50 


0.50 " 


0.75 " 


4 to 7 " 


;.00 or 3.50 " 


0.50 " 


0.75 " 


4 to 7 " 



The method is of so little vogue that we have still to await data 
as to whether infants thrive on it. 

IX. WHEN SHALL THE PHYSICIAN RESORT TO INFANT 

FOODS. 

Under the heading of Infant Foods have been indicated the con- 
ditions under which these foods may be utilized. No conditions 
there laid down presuppose that any infant food may be used as an 
exclusive diet for the infant. Infant foods are only either a tem- 
porary makeshift — where milk for some reason must be excluded 
from the dietary — or they may be added to milk to aid its assimila- 
tion. In the first set of cases belong the infant foods which have 
been indicated under the heading devoted to this subject, such as 
Imperial Granum or the carefully prepared cereals. These foods are 
used in forms of dyspepsia or intestinal disease to tide over a critical 
period. To the latter class belong the infant foods of the malted 
varieties, such as Mellin's Food, which are added to the milk to aid 
its assimilation. In other words, we utilize the diastase or malted 
sugar to aid in the digestion of the proteids of the milk. Inasmuch 
as this aspect of the subject has been fully gone over in a proper 
section, we refer the reader to that section. 



148 ARTIFICIAL FEEDING OF INFANTS. 

Barley-gruels and How to Utilize Them. 

Some physicians object to the addition of barley-gruel in any 
strength to the milk intended for the normal infant, on the ground that 
the gut of the infant is not prepared for the assimilation of starchy 
food, and we find authorities who deprecate the use of barley-gruel for 
the newborn infant, on the ground that it is difficult of digestion. We 
find others who deprecate the use of barley -gruel under all conditions 
other than actual disease. The author's experience does not carry out 
the assertion that barley-gruel is not well borne by the newborn infant. 
On the contrary, some of the most successful cases of infant-feeding 
in his case-book are those of newborn infants whose percentage 
mixture contained as a basis a thin barley-gruel. These cases are 
especially those newborn infants with whom the digestion of the 
proteids is very difficult. He makes up the barley-gruel for these 
infants as follows : A heaping teaspoonful of Robinson's Patent 
Barley is always allowed to a pint of water. This is dissolved, then 
stirred over a gas-flame, brought to a boil, and kept at this tempera- 
ture for fully fifteen to twenty minutes. While the barley-gruel is 
boiling, the amount of milk-sugar requisite for the infant's mixture 
is added. The gruel is then allowed to cool, and the top cream is 
added in the requisite percentage quantity. If prepared in this way, 
we will have greater success than with a barley-gruel only momen- 
tarily heated to the boiling-point. Milk mixtures prepared in this 
way have a consistence of thin gruel and are quite well borne, not 
only by the newborn infant, but throughout the nursing period. The 
use of so-called dextrinized barley in the making of the gruel, on 
the other hand, is not w^ell borne by younger infants, inasmuch as 
there is a greater residue and the solution is not as complete as with 
the ordinary Robinson's Patent Barley. 

Dextrinized barley is rather indicated from the third month to 
the later periods of infancy, and even then this gruel is not as 
well borne by some infants as the ordinary barley -gruel above indi- 
cated. There is no question in my mind that the addition of 
a barley-gruel to a milk mixture aids in the assimilation of the curd 
of the milk. This can be well seen when an infant taking such a 
mixture spits up a small quantity after feeding. The curd thus 
rejected is very finely divided, and closely resembles the curd of 
mother's milk. 

Dextrinized Gruels as Infant Food. 

Jacobi was the first in this country to advocate the addition of a 
cereal decoction to milk in dilutions to aid the digestion of the casein 
in the cows' milk. From this has developed the addition of dex- 
trinized gruels to cows' milk, with the same end in view, Chapin, 



DEXTRINIZED GRUELS AS INFANT FOOD. 149 

in this country, and Keller, in Germany, are the prime movers in 
advocating for certain cases this method of infant-feeding. 

So far as the Chapin method is concerned, it consists principally 
in dextrinizing a thin gruel of barley or flour by means of a diastase 
preparation (Cereo), adding this to the milk, and administering it in 
this fashion to the infant. Chapin advocates the administration of 
dextrinized gruels in combination with milk in percentage dilutions 
both for healthy and sick infants. The author cannot agree with 
him in this, and cannot see the necessity for dextrinizing any dilution 
of milk for the normal infant ; although the author has found the 
method of adding decoctions of barley-gruel to the milk in per- 
centage dilution one of the most useful methods of feeding infants 
with feeble digestion. He has never, however, proceeded to dex- 
trinize a gruel and combine this with milk until he was convinced that 
no other method of feeding the infant would succeed. The author 
feels, therefore, that to dextrinize gruels in combination with cows' 
milk in every case is rather an extreme method of infant-feeding, 
and is uncalled for in a vast majority of cases. 

Keller has advocated the use of these gruels with sick infants, 
especially of the marantic type, and in this respect the author's 
experience carries out the contention of Keller, that much can be 
obtained and brilliant results follow the use of these dextrinized 
gruels. The majority of pediatrists use no other diluent than 
water for the milk of normal infants, and in this respect the 
author's experience agrees with the majority. We shall therefore 
only elucidate this method of infant-feeding with dextrinized gruels 
as it applies to sick infants. In the present method some form 
of diastase, either pure or combined with malt extract, is added 
to the cereal dilution. Chapin takes a tablespoonful of flour, 
adds this to IJ pints of water, and boils the mixture for fifteen 
minutes. He then adds a teaspoonful of a solution of diastase (so- 
called Cereo) to tlie mixture, the gruel becomes thin, and is then 
considered dextrinized. In this form it is added to the milk as a 
diluent in the requisite quantity. The author prefers the Keller 
method. 

Keller utilizes the formula of Liebig in making a malt extract. 
To this malt extract potassium carbonate is added as an animal salt. 
One hundred grammes of this malt extract are added to 500 c.c. of 
water, or 1 pint, and dissolved. This is solution No. 1. He then 
suspends 50 grammes of wheat flour in 500 c.c. of milk, so that the 
solution is quite uniform. He then strains the milk and flour through 
cheesecloth. The solution of malt extract and that of the milk and 
flour are mixed together, put into a common vessel, and stirred con- 
stantly over a slow fire. After about twenty minutes of stirring the 
whole mixture is brought to a boil to stop all processes of digestion. 
The mixture is now put up in bottles, each containing about 6 ounces, 



150 ARTIFICIAL FEEDING OF INFANTS. 

corked, and kept cool. This mixture contains dextrinized cereal and 
malt-sugar in addition to the milk. The Liebig malt extract utilized 
by Keller is composed of maltose, 57 per cent. ; dextrine, 12,4 per 
cent. Wheat contains 66.8 per cent, of starch, 7.5 per cent, of 
dextrine, and a small amount of dextrose. By the action of the 
ferments in the malt extracts — principally diastase — the starches are 
converted into sugars. By this method a number of easily assim- 
ilable substances are introduced into the economy. The action of 
these processes on the casein coagulation seems favorable to its 
assimilation. The Keller method of feeding with dextrinized gruel, 
carried out carefully, is one of the most useful methods of feeding 
marantic infants, and one in which in a great number of cases of 
atrophy has given me brilliant results. I have used this method of 
feeding in cases in which all other known methods have failed. 
These children had been fed on modified milk prescribed in a most 
careful manner by men who may be considered skilful in its admin- 
istration. They had not thriven, and presented the picture known to 
most clinicians under the name of marasmus. Many of these infants 
were quite young, three months of age, and still, by careful admin- 
istration of the Keller dextrinized gruel mixture in proper dilu- 
tion, these infants throve, whereas other foods failed to produce 
the same result. Many of the infants who throve on the Keller 
dextrinized gruel had been subject either to chronic or subacute 
enteric catarrh. Keller has explained his success in feeding this 
class of cases by the fact that in them there exists an acid intoxication, 
emanating from the intestine, which is neutralized by this alkaline 
food. Ammonia is excreted in the urine in increased amount, thus 
indicating a form of disturbed intestinal metabolism. Under the 
administration of this food he found that the ammonia diminishes or 
disappears from the urine. Keller has given these infants malt 
extract without the cereal, but has failed to obtain the same results 
or any increase of weight. 

I have found that the cases best adapted to the use of the Keller 
dextrinized gruel are the infants who remain stationary in weight, not- 
withstanding all attempts at percentage modification of the food, where 
simply cows' milk or cows' milk and cereal decoction alone have been 
used. Another set of cases are the pronounced cases of infantile 
atrophy, primary or accompanied with chronic enteric catarrh, in 
which the body-weight has run down and the infant is brought to us 
weighing 6 to 7 pounds, either too old for a wet-nurse, or in a station 
of life and amid such surroundings as to preclude the use of a wet- 
nurse. It must be said, however, that in feeding these marantic infants 
on dextrinized gruels, containing as they do thoroughly cooked food, 
and coming to us with a previous history of having been fed on 
either sterilized or cooked food for months, we must be exceedingly 
careful not to develop the symptoms of scurvy. When we have 



FEEDING FROM THE NINTH TO THE TWELFTH MONTH. 151 

succeeded, therefore, in placing a marantic infant on a dextrinized 
gruel, and after two or three weeks the infant has begun to thrive, 
we should begin the administration of fruit-juices with the food, in 
order to prevent any scorbutic tendencies. It should be our object 
only in administering dextrinized gruels to increase the body-weight 
to that which would be normal, or nearly so, to the infant of the 
same age, and then gradually return to a milk diet, raw milk being 
preferred in these cases. Of course, when a return is made to a 
milk diet, it must be gradual, and we must be careful that the proper 
dilutions are made, else the old disturbances may return. As a 
matter of experience, we cannot keep these infants on the Keller 
dextrinized gruel beyond a period of three months. If kept longer 
on these gruels the children cease to increase in weight, remain 
stationary, and become anaemic ; but if taken oif in time the brilliant 
result continues. I have experienced no difficulty in a very large 
number of marantic infants in carrying out the above method suc- 
cessfully. 

X. FOOD OF BREAST-FED OR BOTTLE-FED INFANTS 

AFTER THE SIXTH MONTH. 

It has been shown by Caraerer that the secretion of breast milk 
reaches its highest limits, both in quality and quantity, during the 
first six months of lactation. In many cases the quantity of milk 
diminishes, as also its quality. If the infant gains steadily in weight 
after the sixth month, no additional food is indicated. If, however, 
the increase of weight is not satisfactory, we may at this period 
begin with the daily administration of one or two bottles of modified 
cows' milk, in addition to the breast, continued until the infant is 
completely weaned. On the eruption of the incisor teeth, at the 
seventh month, the infant is allowed a cereal, in the shape of pre- 
pared barley, as a pap, with cracker or rusk of bread once or twice 
a day. If the infant is inclined to be constipated, the barley is 
omitted. The same procedure is followed as to cereals with bottle- 
fed infants after the seventh or eighth month. 

XI. FEEDING FROM THE NINTH TO THE TWELFTH 

MONTH. 

Breast-fed Infants. — Weaning. — It is not advisable to attempt 
weaning at the outset of the summer, even though we may be com- 
pelled to keep the infant at the breast a few months longer than 
usual. If the infant is partially weaned — that is, on a mixed feed- 
ing of breast and bottle — it should not be deprived of the breast 
entirely during the summer season. The reason for this is quite 
evident. During the summer a bottle-fed infant is very likely to be 



152 FEEDING FROM THE NINTH TO THE TWELFTH MONTH. 

upset should anything happen to the milk. We would therefore be 
compelled to suspend the feeding with the bottle, proceed without 
milk for a few days, and then gradually return to the milk diet. 
In doing this our task will be less difficult if we have even a scantily 
secreted breast milk at our disposal. Convalescence from a dys- 
peptic attack will be much more rapid if return is made cautiously 
to breast milk than to a substitute feeding. 

It takes about eight weeks to wean an infant completely. Sudden 
weaning of an infant from the breast is not only inadvisable, but in 
some cases attended with the greatest difficulties. If the infant has 
had the benefit of one or two additional bottles daily from the sixth 
month, the task of weaning is comparatively simple. If, however, 
the infant has been kept on the breast exclusively until the ninth 
month, when weaning is attempted certain difficulties Avill at once 
appear. The infant will not take the bottle if there is a breast at 
its disposal. The only way out of the difficulty is to deprive the 
infant at certain times of the day of the breast, and thus starve it 
into taking the bottle. This requires much moral courage on the 
part of the mother and of the physician. In those cases in which 
the mother nurses the infant we cannot always gain her co-operation 
in denying the breast to the infant. The difficulties of weaning in 
such cases are only increased, but with patience we can ultimately 
overcome them. I have seen infants who were deprived of the 
breast at this period refuse to take but a few ounces of nourishment 
daily for weeks. They emaciate, become restless, and refuse to 
be pacified. Under certain conditions, where the nursing function 
has been discontinued and the milk secretion has therefore ceased, 
the situation is at times really critical. But I have invariably seen 
the child take to his artificial food in due season, even if this sur- 
render was delayed for a long period of time. Patience will ulti- 
mately conquer the little one in these cases. 

In weaning I give those modifications of cows' milk which con- 
tain from 1 to 1.5 per cent, of proteids and 2 to 2.5 per cent, of fats 
until the infant is fully weaned. I then increase the strength of the 
milk to that given to the bottle-fed infant at the ninth nfonth. At 
this time the bottle-fed infant is given almost whole milk. It is 
always well to mix with the milk a small quantity of water, in the 
proportion of 1 ounce of water to 7 of milk. Some infants who 
have been at the breast up to the ninth month will apparently refuse 
to take any modifications of milk which contain the cereal decoc- 
tions. In these cases I have tempted the infants with small quanti- 
ties of raw milk slightly diluted with water, foregoing all attempts 
at percentage modification. This seems to have succeeded the best 
in trying cases. 

In addition, the author gives from the ninth to the twelfth month, 
both to breast- and bottle-fed infants, cereals, in the shape of pap 



EIGHTEENTH MONTH TO END OF SECOND YEAR. 153 

made up with barley, granum, rusk, and crackers, twice daily. For 
some of these iufants an ounce of expressed beef-juice is mixed with 
equal portions of barley-water and slightly salted. This is given 
once a day. Infants relish this change. 

XII. FEEDING FROM THE TWELFTH TO THE 
EIGHTEENTH MONTH. 

At this period it is desirable to place the child on a diet contain- 
ing a mixture of milk, cereals, eggs, and beef-juice, in the following 
manner : Five meals are given daily. At each, milk forms the basis 
of nourishment, generally accompanied by rusk or crackers. An 
egg is given once a day, perhaps beginning with the half and in- 
creasing to the whole egg as the infant grows older. At this time, 
also, fruit-juices, such as orange-juice, may be given to infants, 
especially to those who exhibit a rachitic tendency or who are con- 
stipated. The juice of half an orange daily will be relished by most 
infants. 

XIII. SCHEDULE OF FEEDING FROM THE TWELFTH 
TO THE EIGHTEENTH MONTH. 

Milk. — A quart and a half a pint to a pint daily. 

Cereafe.— Rusk or crackers, two of each a day ; sponge cake in 
the form of long sugared slices ; barley, granum, or oatmeal (the 
latter strained) in the form of a pap once a day. 

Eggs. — One soft-boiled egg a day. 

Meat. — Beef-juice expressed, mixed with equal portions of barley- 
water and slightly salted to the taste, about 2 to 4 ounces daily. 

The above dietary is divided into five meals daily. If infants 
are markedly rachitic the author allows, in addition to the above 
dietary, a small amount of chicken meat, as much as will adhere to 
the bone of a chicken. This is given to the child once a day. 

XIV. FEEDING FROM THE EIGHTEENTH MONTH TO 
THE END OF THE SECOND YEAR. 

At this time the child is placed on a mixed carbohydrate and 
nitrogenous diet, consisting for the most part of milk, which is the 
basis of the diet ; eggs ; soup or beef-juice ; meat of the beef or 
chicken ; vegetables ; cereals. These are divided, as in the previous 
period, into five meals daily, as follows : 

Milk. — Some children will take considerable, some very little, milk 
at this period. 

Eggs. — The eggs are boiled soft, as follows : A portion of 
water is brought to the boiling-point, taken from the stove, the egg 



154 EIGHTEENTH MONTH TO END OF SECOND YEAR. 

placed in it, and allowed to remain for two minutes. Some children 
will take at least one Qgg a day, others two. 

Soups. — Parents are apt to overstep the mark in giving large 
quantities of soup — in fact, an adult portion — to children. This is 
scarcely desirable, inasmuch at it displaces other food, such as milk, 
and, containing large quantities of salts and insoluble products, such 
as keratin, soup in large quantities is objectionable. The amount 
should not exceed 4 ounces. 

Meats. — The ordinary boiled meat is by far the best for children. 
The inside of a lamb chop, a small piece of well-done beefsteak, 
roast beef, and chicken. Gamey meats, and fat meat, such as mutton, 
ham, pork, should be avoided. 

Vegetables. — These include potatoes, peas, beans, carrots, spin- 
ach, the green vegetables being especially desirable, inasmuch as 
they contain iron. All vegetables should be given in a mashed 
form. 

Cereals. — These should include barley, rice, granum, wheatena, 
oatmeal, rusk, crackers of all kinds, cocoa, and farina. 

Fruits. — Orange-juice, ripe apples, and pears. 

The articles of diet which should be avoided are vinegar, cabbage, 
salad, coflPee, tea, w^ine, soups that contain too great an amount of 
amylacea. 

A dietary consisting of the above foods might be formulated as 
follows : 

Up to the end of the third year : 

First Breakfast, 8 A. m. : 250 c.c. (8 ounces) of milk, with or 
without a cereal. A slice of bread or crackers and an egg. 

Second Breakfast, 10 :30 a.m. : 180 c.c. (6 ounces) of milk, 1 
rusk, and the juice of half an orange. 

Dinner, 1 p. M. : 120 grammes (4 ounces) of soup ; 75 grammes 
(2.5 ounces) of meat with vegetables, and a fruit dessert. 

Afternoon Lunch, 4 p. m. : 250 c.c. (8 ounces) of milk or cocoa 
with rusk or crackers. 

Supper, 6 : 30 to 7 P. M. : Soft egg, 250 c.c. (8 ounces) of milk ; 
cracker, toasted bread, or farina in the milk. 

Candy. — I allow one or two pieces of candy daily, generally good 
chocolate, to older children. 

From the third to the sixth year of life the diet should be mostly 
fluid or semifluid. The basis of all such diets should be milk. 
Milk soups, eggs, meat, butter, cocoa, bread, fresh vegetables, and 
fruits. The number of meals a day should be five. 

The following is a schedule of a liberal diet at this time : 

Breakfast, 8 a. m. : 330 c.c. (11 ounces) of milk, buttered bread, 
about half an ounce of sweet butter being allowed. 

Dinner, 1 P. M. : 180 c.c. (6 ounces) of soup ; meat, 90 grammes 
(3 ounces), vegetables, a dessert, generally of baked apples. 



THE FEEDING OF SICK INFANTS AND CHILDREN 155 

Afternoon Lunch, 4 p. M. : 240 c.c. (8 ounces) of milk, rusk or 
a slice of bread, or cracker. 

Supper, 7 p. m. : 240 c.c. (8 ounces) of milk mixed with some 
cereal, generally farina, 1 soft egg. 

This is a liberal diet. Some children will take as much as is here 
prescribed, others will take less. Some children are particularly 
fond of fish, and this may be given once or twice a week, generally 
in the boiled form with an egg sauce. Fried fish should never be 
allowed. It is advisable, especially in exceedingly nervous children 
or in those who have a lithic tendency, to substitute meat once or 
twice weekly by fish. 

The above form of diet with slight modifications is suitable up to 
the tenth year of life. The object of all dietaries after the eighteenth 
month is to mix the carbohydrates, fat, and albuminoids in rational 
proportions. The following table by Camerer distinctly demonstrates 
this : 

{Second to Five to Seven to 

fourth vear. six years. ten years. 

12.7 kilos. 18.7 kilos. 24 kilos. 

Total food (daily) . . 1183 grammes. 1517 grammes. 1699 grammes. 

Albumin 46 " 64 " 67 " 

Fat 39 " 46 " 32 

Carbohydrates ... 117 " 197 " 251 

Water 957 " 1200 " 1333 *' 

The Feeding of Sick Infants and Children. 

The feeding of sick infants is considered under the headings of 
the various diseases. It must always be borne in mind that infants 
and children, if left to their own resources, would take either very 
little nourishment or too much. In certain marantic conditions 
infants will take very large quantities of food if it is given to them. 
The infant's cries are interpreted by the mother as being due to 
hunger, when they may be due to colic or intestinal distention. In 
these cases the mother gives too great a quantity of food, and the 
infants suffer from distention of the stomach. In typhoid fever, 
pneumonia, or other acute disease the patient, if fed at long intervals, 
takes but little food. I am in the habit of giving such infants or 
children small quantities at short intervals. If the infant takes a 
small quantity at each feeding, the aggregate amount in twenty-four 
hours is sufficient to maintain nutrition. 

After operations, such as those for empyema, infants and children 
must be carefully and systematically fed up in order that they may 
combat the ravages of disease. The necessity of careful feeding is 
seen in typhoid fever in the fifth and sixth weeks, at which time 
there is great emaciation and the temperature has dropped to the 
normal. If we fail to feed up the patients, they remain emaciated 
and show slight inanition temperatures. On the other hand, we must 



156 THE FEEDING OF SICK INFANTS AND CHILDREN. 

not give large quantities of indigestible food. We must choose the 
foods carefully. Convalescents can take much larger quantities of 
food in twenty-four hours than the normal, healthy child. The 
quantity given at each feeding should be smaller than in health. 
The nitrogenous foods, such as milk and eggs, and also sugars, 
starches, and cereals of all kinds, are easily assimilable. Alcoholics, 
when given, should be well diluted. Rectal feeding is contraindicated 
in diarrhoeal conditions and states of rectal intolerance. On the 
other hand, if the stomach rejects food repeatedly, it is w^ell to give 
that organ complete rest. Under such conditions even water is not 
introduced into the stomach. The patient is fed for twenty-four 
hours or more by rectum. 

References of Authorities for Collateral Reading. 

Ahlfeld: Ueber d. Ernahrnng. d. Saugl., etc., 1878. 

Alix and Vierordt: "Temperatures," Gerhardt's Hand-book, vol. i. 

Backhaus : " Milch Analyse," Berlin, klin. Woclienschr., 1895. 

Baginsky, A.: Antipyrese, etc., Berlin, 1901. 

Budin, P. : Le Nourisson, Paris, 1900. 

Camerer, W. : Der StofFwechsel des Kindes, etc., 1894. 

Cantani: "Cholera Behandlung," Berlin, klin. Wochenschr., 1892. 

Chapin, H. D. : N. Y. Med. Jour., February, 1901. 

Conrad, F. : Die Untersuch der Frauenmilch, 1880. 

Czerny and Keller: " Ernahrungsstorungen," etc., Vienna, 1901-2. 

Doane and Price : Maryland Agricul. Bull., 77. 

Eross, Julius: Ueber die Sterblichkeit Cong. Hygiene, 1894. 

Escherich : " Morbiditat," etc., Jahrbuch. fiir Kinder, dritte folge, Bd. i. Heft 1. 

Epstein, A. : "Cholera Infantum," Henoch Festschrift, 1890. 

Fehling : " Form des Beckens," Arch. f. Gyn., vol. x. 

Fournier : Syphilis hered. tarda, 1886. 

Herz, P. : Dissertation, Klin. Untersuch. Neugeb., 1900, 

^e//er; Malzsuppe, Jena, 1894. 

Knopfelmacher : Ernahrung mit Kuhmilch, 1894. 

Konig, J.: " Chemie," 4th ed. 

MacDonald: "Experimental Study of Children," U. S. Bureau of Education, 1899. 

Marfan, A. B., by Fischl: " Sauglingsernahrung," Leipzig, 1904. 

Meigs, A. V. : Milk Analysis and Infant-feeding, Philadelphia, 1885. 

Preyer : Die Seele des Kindes, Leipzig, 1890. 

Rotch, T. M. : Transactions Amer. Psediatric Soc. 

Schlichter : Untersuch. u. Wahl der Amme, Vienna, 1894. 

White and Lladd: Phila. Med. Jour., February 2, 1901. 

Wrobelewski, A. : Beitrag zur Kennt. des frauen Caseins, 1894. 



SECTION III. 

DISEASES OF THE NEWBORN. 
I. PHYSIOLOGY OF THE NEWBORN. 

Respiration. 

Inasmuch as cardiac action and muscular movement occur 
during the intra-uterine life of the foetus, the first important 
function performed by the newborn infant is that of respiration. 
The cause of the first inspiratory act of the newborn has been a 
matter of much discussion ; whereas some contend that mechanical 
stimulus brought into play by the act of parturition is the primary 
cause of the first inspiratory act of the infant, others have insisted 
that the change of temperature from the uterus to that of the ex- 
ternal world, acting on the surface of the body, is sufficient stimu- 
lus to cause, by reflex action, the first act of inspiration. Both 
these theories have been disproved, especially by the work of Ahl- 
feld. The consensus of opinion is, that the first inspiration of 
the newborn is a direct result of the separation of the placenta 
with the cessation of the normal foetal aeration of the blood ; as a 
result of this there are diminution of oxygen in the foetal blood, 
increase in carbonic-acid gas, and marked stimulation of the res- 
piratory centre of the newborn in the medulla. This theory is borne 
out by the fact that in premature separation of the placenta this 
stimulus to the performance of inspiration on the part of the foetus 
occurs before birth in the uterus or in any part of the parturient 
canal. There are rare cases also in which the foetus is born before 
separation of the placenta from the w^alls of the uterus. In such 
instances the birth has been very rapid and the resistance to the 
passage of the foetus slight ; as a result of the uterus having con- 
tracted but little, the placenta remains in situ for a short space of 
time after birth of the foetus. Such a case has been published by 
Kehrer, and in this case the foetus was born in a state of uterine 
apnoea, the color of the skin being pink, the infant not breathing, 
but at most performing the intra-uterine respiratory movements of the 
trunk, as described by Ahlfeld. Such cases would seem to prove the 
truth of tlie theory that if the placenta still remains attached to 
the uterine walls, and the interchange of oxygen between the maternal 

157 



158 PHYSIOLOGY OF THE NEWBORN. 

and foetel blood continues, the stimulus to the medullary centres 
mentioned above is lacking. There is thus no inspiration in such 
cases until the placenta separates. Ahlfeld has shown that in utero 
the foetus performs certain rhythmic movements of the trunk and 
extremities, which he interprets as respiratory in their nature. 
There are thus, according to these experiments, respiratory move- 
ments performed by the foetus in utero. These, however, are of the 
most superficial character, and do not lead to aspiration of liquor 
amnii either by mouth or nostrils. It is the intensification of these 
intra-uterine respiratory movements which eventuates in the first act 
of respiration of the newborn. Though the existence of intra-uterine 
foetal respiratory waves as conducted by the liquor amnii to the 
uterine wall have been verified by a number of observers, their in- 
terpretation is diverse and their significance is still a matter of dis- 
cussion. 

The rhythm of respiration in the newborn is quite irregular. 
Deep inspiration and expiration are followed by regular respiration, 
with an apparent pause in which the respiratory movements are so 
superficial that the infant scarcely seems to breathe, and in which 
the respiratory movements can only be detected by the chymograph, 
this in a manner recalling the intra-uterine respiration of Ahlfeld. 
During sleep the respiration is more regular, but is influenced by 
the least external source of disturbance, such as a change in the sur- 
rounding light, air, and covering of the newborn. 

The frequency of respiration can thus be of varying rapidity. 
Dohrn found that, regardless of sleep or waking, the number of res- 
pirations of the newborn was on the average 62 ; during the act of 
crying 47. 

The type of respiration in the newborn, either in the male or 
female, is predominantly thoracic. 

The aeration of the lungs — that is, the replacement of inspired 
by expired air — is much more thorough in the lungs of the newborn 
than later in life. In other words, if, as has been proved by Dohrn, 
38 c.c. of air are inspired on the first day of life, this is renewed 
by each inspiration and expiration to such an extent that there is 
little residual air in the lung. In the adult lung the contrary 
obtains, there being, even on forced expiration, enough air left in 
the lung and retained there to be demonstrated by collapse of the 
organ when the thorax is opened and atmospheric pressure is allowed 
to act on the viscus. In the newborn, if the thorax is opened post- 
mortem, no such collapse of the lung takes place, but enough air 
remains in the organ to enable it to float if placed in water — that is, 
a minimum amount of air. The lung of the newborn unfolds 
gradually, so that in an infant two weeks old there are patches of 
the lung which have still not been aerated, although the infant has 



CTRCULATIOK 159 

breathed normally all this time. That the lung does nniold gradu- 
ally is proved by the fact that, while immediately postpartum, 
38 c.c. of air are taken into the lungs with each inspiration, this, 
on the tenth day of life, has increased to a volume of 50 c.c. 

Circulation. 

At the moment of bfrth of the infant certain changes take place 
in the circulatory system which mark the transition from intra-uter- 
ine as distinguished from extra-uterine life. These changes occur 
in the foramen ovale, the ductus Botalli, and the umbilical arteries 
and veins. On the first inspiration the lungs expand and the blood 
passes into the organ. The pressure is immediately lowered in the 
right auricle on account of the diminished resistance of the pulmo- 
nary capillaries ; the pressure in the left auricle is correspondingly 
increased. The foramen ovale, situated in the auricular septum, 
with a valvular slit-like opening toward the left auricle, is naturally 
closed by the increased pressure in the left auricle, and from thence 
forward there is no interchange of blood between the right and left 
auricle as in foetal life. 

The closure of the ductus Botalli is a matter of much discussion. 
The explanation of its closure given by Strassman is now accepted 
by most observers. On expansion of the lungs and the establish- 
ment of the smaller pulmonary circulation, the pressure in the pul- 
monary artery is diminished and that in the aorta increased. The 
ductus Botalli, passing as it does from before backward from the 
pulmonary artery to the aorta, enters the latter vessel at an acute 
angle. Its lumen at the aortic extremity is funnel-like and closed 
by a slit-like valvular arrangement, whereas during foetal life, the 
pressure being greater in the pulmonary artery than in the aorta, it 
was possible for blood to pass through the ductus Botalli into the 
aorta. At birth, the pressure conditions being reversed, it becomes 
impossible for blood to pass from the pulmonary artery to the aorta, 
the pressure in the pulmonary artery not being equal to driving the 
blood through the ductus against the increased postnatal pressure 
in the aorta. The ductus thus becomes emptied, and its function as 
a circulatory organ connecting the pulmonary artery and the aorta 
ceases. No clot is formed except in rare cases in the lumen of the 
ductus. In utero, from the fifth month on, there is a gradual dimi- 
nution in the calibre of the vessel ; within two or three days after 
birth the calibre is so narrowed that a probe cannot be insinuated 
within it. The aortic extremity in many cases is never entirely oc- 
cluded, although most of the vessels become subsequently obliterated. 

At birth the umbilical arteries are closed by a process similar to 
that which is described above. The first inspiration with conse- 



160 PHYSIOLOGY OF THE NEWBORN. 

quent inflation of the Inng and the establishment of the pulmonary 
circulation causes a fall of arterial pressure in the descending aorta. 
The blood ceases to flow through the umbilical arteries. The mus- 
cular coats of these vessels, being particularly well developed, tend 
to contract, and enclose in their lumen an extended fibrinous clot. 
When the cord is tied this clot extends from the umbilicus to the 
hypogastric arteries. It is the adherence of the thrombi to the walls 
of these vessels and their subsequent organization which causes the 
obliteration of the lumen of the umbilical arteries, although this is 
not complete except at the situation of the umbilicus. The umbili- 
cal veins are obliterated in a physiological manner by the pressure 
of the uterus on the placenta. This forces the reserve blood in the 
placenta into the body of the foetus, the act of inspiration favoring 
the flow of blood from the placenta to the body of the foetus. Budin 
has shown that if the umbilical cord is divided too soon after birth blood 
to the amount of about 100 c.c. flows from the veins. If ligation 
of the cord is delayed, however, this quantity of blood is aspirated, 
so to speak, by the infant into its body from the placental sinuses. 

After ligation of the cord, therefore, the natural physiological 
condition of the circulation favors the collapse and obliteration of 
the umbilical veins. 

Pulse. 

The pulse of the newborn infant is irregular in frequency and 
shows certain constant characteristics. Immediately after birth the 
frequency reaches 150 to 190 beats a minute. This rapidity is due 
probably to the new conditions inaugurated at birth in the circulation 
and the increased amount of work, caused by respiration and pulmo- 
nary circulation, thrown upon the left ventricle. After a short lapse 
of time, from twenty minutes to an hour after birth, the pulse fre- 
quency sinks to less than 100 during sleep. During waking, 
nursing, crying, muscular exercise, there is a slight increase in fre- 
quency. After three to five days the pulse mounts in frequency from 
120 to 135 beats per minute, but never again attains the rapidity 
observed immediately after birth. The rise in frequency of the 
pulse after its primary fall may be due not only to the recovery of 
the circulatory system, especially the heart, from the effects of rapid 
changes of tension in its various ]:>arts, incident to the new extra- 
uterine conditions, but to the beginning influence of the vagus on 
the left ventricle. 

The influence of sex on the frequency of the pulse is evident in 
the newborn as in later life, the pulse of girls during sleep being 
two or three beats more frequent to the minute than that of boys. 
During exercise the pulse of the male newborn infant is more fre- 
quent than that of the female. The true cause of these differences 
is as yet obscure, 



DIGESTIVE FUNCTIONS, 161 



Blood. 



The amount of blood of the newborn as compared with the body- 
weight varies with the time of ligation of the umbilical cord. If the 
cord is ligated at once the quantity of blood is one-fourteenth to one- 
sixteenth of that of the body- weight ; whereas in cases of late liga- 
tion of the cord it is one-tenth to one-eleventh of the body-weight. 

The histological characteristics of the blood of the newborn are 
so striking as to merit brief mention here. The blood contains a 
large number of nucleated red blood-cells ; the red blood-cells do 
not tend to collect in rouleaux, and show very little or no central 
depression, as later on. The number of red blood-cells is not only 
greater to the cubic millimetre than later in infancy, but the haemo- 
globin percentage of the blood and of the individual erythrocyte is 
much higher than later on. The red blood-cells show also the cen- 
tral '' shadows " to a greater extent than is seen later in infancy. 
The white cells are present in larger numbers relative to the red 
blood-cells than later in infancy, and this proportion is still greater 
after feeding. 

The white blood-cells have a marked tendency also to group 
themselves in clumps. These characteristics of the blood gradually 
disappear toward the eleventh day, and are most pronounced on the 
fourth day after birth. It can thus be seen that the blood picture 
obtained during the first days of life is such as would be of grave 
pathological import if found in the adult. 

Digestive Functions. 

The saliva is secreted in much less quantity in the newborn than 
later in infancy, and is present in just sufficient amount to moisten 
the mucous membrane of the mouth. Its reaction is slightly alka- 
line, but in disturbed conditions of the mucous membrane of the 
mouth it becomes acid. The amyllolitic ferments are present only 
in the secretion of the parotid gland, and here only to a slight 
degree. The secretion of the submaxillary gland shows this prop- 
erty only after the third month of infancy (Zweifel). 

Pepsin is found in the stomach of the embryo at the fourth 
month, whereas hydrochloric acid is found in this organ only during 
the later months of foetal life. Both are present in the stomach of 
the newborn infant. 

The pancreatic secretion in the newborn, while incapable of con- 
verting starch into sugar, does contain trypsin and a fat-splitting 
ferment. 

The properties of the secretions of the mucous membrane of the 
intestine of the newborn are still a matter of speculation. The gall- 
bladder of the newborn infant contains 0.1 to 0.3 grammes of bile, 
11 



162 PHYSIOLOGY OF THE NEWBORN. 

which is increased in amount after the ingestion of food. The bile 
contains less water and is richer in mucin, coloring-matter, and 
taurocholic acid in the newborn infant than at any other time of 
life. Glycocholic acid is not found in the bile of the newborn. 
The physiological function of the bile is still undetermined. 

From the above it will be seen that in the newborn infant the 
digestion of starchy substances is but feeble, whereas the digestion 
of fats and albuminoids is as complete as in later infancy. 

Body-temperature . 

The rectal temperature of the infant taken immediately after 
birth is about 0.6° C. higher than that of the mother. The average 
temperature of the newborn subsequent to depressions incident to 
the immediate postnatal period is 37.7° C. (99.6° F.). Febrile 
states of the mother at the time of parturition, or external influences, 
may cause a rise or fall of the body-temperature in the newborn. 
Thus, a case is recorded in which an infant born of a mother suffer- 
ing from fever at the time of labor had a temperature of 41° C. 
(105.8° F.) immediately after delivery (Lange, Fehling). Prema- 
ture or congenitally w^eak infants have a low^er rectal temperature 
than vigorous full-term infants. An hour or two after birth the 
body-temperature falls, but after nine to seventeen hours attains 
37° C. (98.6° F.). This fall may be as much as 1.7° to 2.5° C, 
and is due to the cooling influence of the first bath, the change from 
the warmth of the uterine cavity to the external air, and the respira- 
tion. Toward the end of the first week the body-temperature of 
the newborn rises slowly to the permanent normal by tenths of a 
degree. In the congenitally weak the temperature rises more slowly 
and reaches 37° C. after twenty-four hours ; whereas in strong and 
well-developed infants it reaches this limit in one-quarter to one- 
half this time. The temperature of the newborn is more easily 
depressed and raised by external influences than that of the adult. 
Thus, clothes and the surrounding atmosphere exert a marked influ- 
ence in this respect. There is also a direct relation between the 
amount of nourishment ingested and the body-temperature. If the 
nutriment is insufficient, the normal temperature is attained much 
more slowly than under contrary conditions. An illustration of the 
influence of external conditions on the temperature is the case of a 
congenitally weak infant recently brought to my notice, whose tem- 
perature was raised fully 0.6° C. (1.5° F.) above the normal by pla- 
cing warm-water bottles too near the body. The temperature of the 
newborn, therefore, is subject to wide variations ; but it may be said 
that after the second day a temperature below 36° C. (96.8° F.) or 
above 38° C. (100.4° F.) is abnormal. The diurnal fluctuation of 
the body-temperature of the newborn is characteristic in that the 



BREASTS. 163 

highest point in the curve is reached in the early morning (6 A. M.) 
rather than in the evening, as in the adult. 

Skin. 

The body of the newborn infant is covered with a grayish, cheesy 
material, which consists of epithelial scales and secretions from the 
sebaceous glands, called the vernix caseosa. As is well known, this 
is washed off after birth, and leaves the skin smooth and of a uni- 
form pink color. The skin of the newborn infant desquamates in 
small and large scales. This is distinctly noticeable at the sixth or 
seventh day, and ends in the second or third week after birth. 
Small vesicles are seen to form here and there on the skin over the 
body in some infants. 

The body at birth is covered with soft, long hair called lanugo. 
This is also found on the scalp. In the first few weeks after birth 
this hair falls out and is replaced by the permanent hair. In weak- 
lings this replacement, as also desquamation of the skin, takes place 
more slowly than in stronger infants. In the first few weeks the 
sebaceous glands are especially active, and their activity is indicated 
by the appearance of the so-called scurf on the scalp. On the body, 
in the groin, on the nose and face, small white - bodies are noticed in 
the newborn infant, called milia. Epstein showed that these were 
really retention cysts of sebaceous follicles of the skin. They dis- 
appear in the course of two or three weeks. 

Jaundice. — The skin, though pink in color at birth, becomes 
jaundiced from the second to the fourth day after birth in 80 per 
cent, of newborn infants. 

Perspiration. — Although infants are hardly seen to perspire pro- 
fusely unless warmly clothed, the insensible perspiration from the 
skin and lungs is proportionately greater for the expanse of the body 
surface than in the adult. Rubner and Heubner showed that the 
infant yielded 

During the first week fully 90 grammes (3 ounces) ; 

" " second and third months 192 grammes (6^ ounces) ; 
" " fifth and sixth " 290 grammes (9f ounces) ; 

" " first year 460 grammes (15^ ounces) 

of insensible perspiration daily, as compared with 650 grammes (21f 
ounces of the adult. 

Breasts. 

From the third to the fifth day after birth milk appears in the 
breasts of the newborn infant of both sexes. As a rule, the secre- 
tion appears earlier in the breasts of girls than in boys. The breasts 
become swollen and tense ; one gland, generally the right, function- 
ating sooner than the other. The cause of this curious phenomenon 



164 



PHYSIOLOGY OF THE NEWBORN. 



is as yet unknown. Balantyne suggests that it is due to a bio- 
chemical relation between the foetus and the mother, which exercises 
its influence on the infant after birth in such a way that the same 
agencies which cause a production of milk in the mother continue 
to produce the same result in the infant. The secretion has been 
examined by Barfurth, Herz, and others, and has been found to be 
composed of proteids, 2.5 to 2.6 per cent. ; fat, 2.3 to 3 per cent. ; 

Fig. 23. 




Caking of the milk in botli breasts of a newborn infant. 



sugar, 2.5 per cent. It is therefore a real secretion of milk, and 
the method of its secretion is the same as in the adult gland. The 
amount of milk, which is called by the laity " witches' milk,'' is 
small. The secretion lasts, as a rule, from six to eight weeks ; in 
exceptional cases it may continue six months (Herz). If mastitis 
occur, it is certainly the result either of antepartum or postpartum 
infection, and not of caking of the breasts. 



URINE. 165 



Urine. 



Speaking of the urine of the newborn in a stricter sense, the 
amount passed spontaneously after birth is on the average 9.6 c.c, 
of which 7.5 c.c. may be found in the bladder at the time of birth, 
unless the viscus has been subjected to pressure during birth. The 
urine is passed spontaneously within twenty-four hours after birth 
in 66 per cent, of newborn infants, and in the remaining cases within 
forty-eight hours after birth. 

The daily quantity of urine during the first two weeks varies 
widely according to different observers. On an average the amount 
varies in breast-fed and bottle-fed infants according to the amount 
of fluid food ingested. In breast-fed infants the amount during the 
first three days increases from 17 c.c. to 43 to 49 c.c, and on the 
fourth day amounts to 116 c.c, due to an increase of milk in the 
mother's breast. On the fourteenth day the amount has run up to 
263 cc 

Hofmeier and SchifP have shown that infants in whom the cord 
has been tied early, and in whom the gross amount of blood in cir- 
culation is less than in those in whom the cord has been tied late, 
the daily quantity of urine will be proportionately less. As soon as 
a constant relationship is established between the amount of fluid 
taken into the body and that excreted, toward the seventh day, then 
the amount of urine excreted reaches the proportionate relationship 
to the body-weiglit that exists in the adult. Thus, whereas on the 
first day 21.8 to 38.8 per cent, of the milk taken is excreted 
in the form of urine (Cruse, Reusing), on the eighth day it reaches 
the constant proportion of 62.8 per cent., as in the adult. The 
amount of urine proportionate to each kilogramme of body-weight 
must necessarily increase more markedly during the first eight days, 
inasmuch as, while the body-weight during this time is more or less 
stationary, the gross amount of urine increases. Thus, the first day 
it amounts to 5.9 c.c. to each kilogramme ; on the eighth day it 
reaches 67.4 c.c, on the tenth day 90 c.c, and then remains station- 
ary. These figures are higher than is true of the adult, in whom 
the daily amount of urine per kilogramme of body- weight is 25 cc 

The urine of the newborn is almost colorless ; its specific gravity 
in the foetus 1002.8 (Dohrn) ; in the first two days of life 1008 to 
1009, on the third day 1011 to 1013, and on the tenth day it falls 
to 1003 to 1004. In bottle-fed infants the specific gravity is lower 
than in the breast-fed infant, due to the increased amount of milk 
ingested. The reaction of the urine of the newborn is constantly 
acid in all but 3 per cent. (Hofmeier). The urine of newborn 
infants during the first five days of life contains renal epithelium, 
uric-acid crystals, amorphous urates, and frequently casts. Hyaline 
and granular casts were found by Reusing in 39.4 per cent, of 



166 PHYSIOLOGY OF THE NEWBORN. 

breast-fed and in 9 per cent, of bottle-fed infants during the first 
days of life. If casts are present, there is also, as a rule, albumin. 

The amount of urea increases absolutely and relatively from the 
first day of life. Thus, it increases in absolute quantity from 0.06 
to 0.11 the first day, to 0.82 on the eleventh day, or, relatively to 
each kilogramme of body- weight, 0.018 to 0.29 on the seventh 
day. 

Uric acid is present in the urine of the newborn in remarkably 
large amounts. Thus, on the fist day the urine contains 0.0136 of 
uric acid to each kilogramme of body -weight. That is much greater 
than in the aflult. The proportion of uric acid to urea is much 
greater in the newborn than at any other period of life ; in the adult 
it reaches the high relative percentage of the newborn only in patho- 
logical states. Thus, in the adult the relative proportion of uric acid 
to urea is as 1 : 41 or 61, whereas in the newborn it ranges from 
1 : 1.5 on the first day to 1 : 21.9 on the seventh day of life. 

Albumin is found immediately after birth in the urine in 38 
per cent, of infants (Dohrn). Dohrn ascribes its presence as 
due to complications during birth or disturbances, however slight, 
of the circulation. Hofmeier found it disappeared toward the end 
of the first week ; also that there was a constant relationship between 
the excretion of uric acid and the presence of albumin in the urine 
of the newborn, the latter being absent in those cases in which 
uric acid was not found and in which no uric acid infarction of 
the kidney existed. He attributed the albuminuria of the newborn 
to the mechanical irritation of the deposits of uric acid on the epi- 
thelium of the uriniferous tubules. 



Rectal Excreta. 

Meconium forms the gut content in the foetus. It is of a 
yellowish-green color in the small intestines — of a dark-green color 
in the large gut, becoming lighter after an interval of a day or so 
after birth. It is of a tarry consistence and odorless. The total 
quantity of meconium varies from 70 to 90 grammes, or 2 J to 3 
ounces, of which 2 to 20 grammes are passed daily. When the 
infant takes the breast or cows' milk, meconium is mingled in the 
movements with the milk fseces. The first passage of meconium 
occurs immediately after or in the first few hours, at the latest ten 
to twelve hours, after birth, and is preceded by the expulsion of 
the so-called meconium plug. This is a body of mucoid tissue 2 
millimetres in diameter, and is of importance in a medico-legal 
sense. An infant stillborn will retain in the lower part of the rec- 
tum the meconium plug. 

The stools for the first two days consist mostly of meconium, 
which subsequently becomes mingled with the milk fseces. The 



NERVOUS SYSTEM. 167 

movements contain both yellow and greenish residue. After 
the fourth dav the infantile movements assume their perma- 
nent characteristics of color and consistence. The composition of 
meconium has been fully investigated. It is made up of desquama- 
ted epidermal and intestinal epithelium, amniotic fluid, vernix case- 
osa, wool-hair or lanugo, plates of cholesterin, scales of skin, 
hsematoidin crystals, bilirubin, fat-drops, and stearic-acid crystals. 
Bilirubin is peculiar to meconium (Zweifel and Schmidt). Wein- 
traud found uric acid and alloxur bases in meconium, which were 
probably derived from a nuclei n substance. Schild found that ster- 
ile meconium contained a peptonizing ferment ; and Patevin found 
a lab-ferment and amylase in sterile meconium. 

Meconium contains also the characteristic so-called '^ meconium 
bodies." These consist of ovoid or polyhedral masses yellowish- 
green in color. They are made up of organic matter, such as 
masses of intestinal epithelium and mucus, in which are precipi- 
tated biliary pigments and salts. They contain biliary pigment, 
soluble in caustic potash, insoluble in ether or acetic acid. 

Chemical analysis of meconium reveals mucin, palmitin, stearin, 
olein, biliary pigments, and taurocholic acid. It does not contain 
indol or phenol, which are products of decomposition. 

During the first few days of infancy the stools contain much 
mucus of a stringy character, and the writer has frequently seen 
this actually drawn out of the rectum in shreds by the nurse in 
otherwise normal infants. 

Bacteria. — Meconium is sterile at first, and then becomes 
infected with bacteria in from three to eighteen hours after birth. 
A pro tens similar to that of Hauser's is regularly found, also a 
chain coccus and a Bacillus sub tills. With the appearance of the 
milk faeces, a bacillus similar to that of the Bacillus lactis aero- 
genes is found in the upper part of the gut, the colon bacillus in 
the lower portion with the coccobacillus of Fischl. 

Nervous System. 

The nervous system is not in an active, but rather in a recep- 
tive, state in the newborn. 

Muscular power as well as muscular sense is but little devel- 
oped. The newborn infant can neither sit up nor hold its head 
upright. The reflex irritability of nerve and muscle both to gal- 
vanic or faradic stimulus is less evident in the newborn than later 
in infancy or in the adult. Response to stimulation is distinctly 
delayed ; the latent period is more marked in the newborn. In the 
newborn the inhibitory functions of the vagus are not fully devel- 
oped, but it is susceptible to reflex action, as is demonstrated in cases 
of cerebral pressure with slowed pulse due to injury incident to 



168 PHYSIOLOGY OF THE NEWBORN. 

birth. In these cases the vagus would seem to exert through the 
cerebral centres an inhibitory influence on the heart. The cerebrum 
seems to be in a passive rather than in an active state in the new- 
born. In spite of the divergence of views, there seems to be no 
sign of consciousness in the newborn, nor are the motor centres 
developed to such an extent as to react under stimulus. Motion is 
rather of a reflex nature or indirectly referable to the high develop- 
ment of the sense of touch. Thus, we meet with injuries of the 
skull-cap in the newborn which are of an extensive character, such 
as depression of the skull, giving no symptoms referable to the 
motor areas. On the other hand, there is sufficient reason to believe 
that the cerebrum exerts a negative inhibitory influence, and that 
several of such centres are active in the newborn. The skin reflex 
presents nothing peculiar in the newborn. The patellar reflex is 
somewhat increased, diminishing after the seventh to the nineteenth 
day. 

In spite of the assertions of Kussmaul and Preyer as to the 
existence of the sense of taste in the newborn, there is reason to 
believe that this sense is but little developed, and really exists in 
the nature of a reflex rather than a sense which distinguishes between 
sweet, bitter, and sour, as in the adult (Gensmer). Thus, Lange 
has given a 4 per cent, quinine solution to the newborn without 
awakening any signs as to the appreciation of its bitter taste. It 
is also questionable whether the newborn appreciates the sweet taste 
of breast milk. On the whole, it may be said that it takes a strong 
solution of any kind, sweet or bitter, to cause any visible reaction 
in the newborn, and that this reaction is rather in the nature of a 
general reflex than an appreciation of differences of sweet, sour, or 
bitter. 

Hearing is not evident as a sense immediately after birth, and, as 
has been pointed out elsewhere, the newborn infant is deaf. The 
sense of hearing develops at various periods after birth, from six to 
forty-eight hours, according to the rapidity with which in the new- 
born the Eustachian tube is opened up and air enters the internal ear. 
In prematurely born infants, on account of marked swelling of the 
walls of the tube, the development of the sense of hearing is much 
delayed. These facts explain the wide difference among observers 
(Kussmaul, Preyer, Gensmer) as to the development of this sense. 
Gensmer is probably correct when he says that most infants react to 
sound after the first or, at least, the second day. The improvement 
in the hearing is unmistakable in the first week. 

In the premature as well as in infants born at full term, the eye 
reflexes are developed. Thus the pupil contracts and dilates under 
stimulus, and intense light or continued flashing of light in the 
vicinity of the newborn calls forth signs of general reflex irrita- 
bility ; that is, the newborn becomes uneasy under irritation of this 



EXCRETION AND WASTE. 169 

nature. It is still a matter of discussion as to whether the newborn 
can fix or focus objects and whether accommodation is developed. 
The eyelids react promptly to reflex stimulus. 

The sense of smell is but slightly developed in the newborn, and 
it is a matter of question as to whether at this time the infant may 
recognize the mother or the nipple of the breast by means of this 
sense. Far more probable is it that in this respect the sense of 
touch and its reflexes has been mistaken in its manifestations for that 
of smell. 

The sense of touch is the most highly developed sense in the new- 
born, and is most evident in the lips and face. The lip reflex is 
especially developed, inasmuch as in the newborn the least contact 
of any object with the lips calls forth the pursing of the lips and the 
motions attendant on suckling. 

The appreciation of pain is absent immediately after birth, and 
only after one or two days does the newborn react to the irritation 
of a pin-point. 

But little is known of the appreciation of heat and cold in the 
newborn ; and it may be said that these call forth only manifesta- 
tions of a general reflex action as is seen in cases of asphyxia when 
infants are brought rapidly from the warm to the cold plunge. 

Metabolism. 

Though much is still to be learned as to the processes of metabol- 
ism in the newborn, there are certain facts as to the daily quantity 
of milk taken, the amount of urine voided, the loss of weight by 
means of the skin and faeces, which have been determined within 
certain limits. 

The amount of milk consumed daily by the newborn has been 
carefully determined by weighing the infant before and after nursing. 
A well-developed infant nursing a normally secreting breast will, 
according to the investigations of Cammerer, Hahner, and Laure, 
consume the following quantities of milk, expressed in cubic centi- 
metres : 

Davs. ..12 3 4 5 6 7 8 9 10 H 12 13 14 15 
33 123 209 290 305 342 400 417 426 413 441 437 516 487 536 

Excretion and Waste. 

Meconium and Fseces. — As long as meconium is voided (60. to 
90. grammes) the movements are small. As soon as milk faeces 
appear they average 1 to 3 grammes of fseces to 100 c.c. of milk 
ingested. An infant during the first two weeks rarely voids more 
than 10 grammes of fseces daily. The excretion of carbonic-acid 
gas and water by the skin and lungs has as yet not been accurately 



170 



PHYSIOLOGY OF THE NEWBORN. 



determined. The experiments of Forster as to the excretion of car- 
bonic-acid gas were performed on a fourteen -day-old infant. His 
observations were made on the sleeping infant only, also a source of 
error. Cammerer, however, determined the daily exhalation of 
carbonic-acid gas more definitely, and found that this was as follows : 



1st day. 2d day. 3d day. End 1st week. End 2d week. 

100 grammes 85 grammes 80 gmmmes 100 grammes 130 to 150 grammes 

It may be said that under similar conditions the newborn infant 
exhales more carbonic-acid gas per kilogramme of body-weight than 
the adult. 

Though certain facts as to the metabolic processes are as yet un- 
determined in the newborn, we can still form an approximate estimate 
as to the ultimate disposition of the food and the manner in which 
oxidation processes of the body are carried out in the first few days 
of life. Thus, Cammerer has by estimating the amount of food 
ingested, and the amount of urine, faeces, and carbonic-acid gas 
excreted, drawn up a very instructive table showing the loss of Aveight 
and the manner in which it is kept within certain limits during the 
first four days of life : 



Day. 


Milk taken. 


Excreted. 


Loss of weight. 


1 


10.0 


Urine 


. 48.0) 








Meconium 


. 51.0 \ 


185 






Co, 


. 96.0 j 
195.0 




2 


91.5 


Urine 


. 53.0 1 








Meconium . .^ . . . 
Faeces 


. 23.0 1 
. 3.0 ( 


72 






C02 


. 84.5, 
163.5 




3 


247.0 


Urine 


. 172.0) 








Faces 


3.0 [ 


10 






C02 


. 82.0 J 
257.0 




4 


337.0 


Urine . 


. 226.0) 






Faces 


2.5 I 


+ 15 






C02 


. 93.5) 
322.0 





Thus, the loss of weight during the first four days is due in great 
part to the lack of sufficient nourishment to compensate for the loss 
through the urine and faeces. 

In order to illustrate more completely the oxidation processes in 
the body, Cammerer has reduced the food and excreta to their chemical 



MORTALITY AND SUDDEN DEATH IN THE NEWBORN. 171 

elements. The C. H. N. and O. taken into the body in the form 
of nourishment and inhaled oxygen are compared to the same ele- 
ments excreted in the urine, faeces, and the expired air. It is seen 
that in the newborn, as in the adult, fully 93.4 per cent of the carbon 
taken in is excreted in the carbonic-acid gas, the nitrogen being 
excreted for the most part in the urine. Whereas, however, in the 
adult the nitrogen taken in is excreted entirely in the urine and faeces ; 
in the newborn fully half the nitrogen is retained in the body. 

Infant Fourteen Days Old, Weighing 3500 Grammes. 



Taken into the body in 
twenty-four hours. 


Water. 


c. 


H. 


N. 


0. 


Ash. 


Milk. 

Inspired 


500.0 
70.2 


444.0 


29.5 


4.5 
49.3 


2.0 


18.4 

70.2 

394.7 


1.6 




444.0 




Urine voided . . . 

Faeces 

Co, 


570.2 

350,0 

7.0 

185.1 


444.0 

347.0 

5.0 

104.1 

456.1 


29.5 

0.7 

0.8 

22.0 


53.8 

0.1 
0.1 

50.7 


2.0 

1.0 
0.1 


483.3 

0.7 

0.3 

59.0 

405.4 


1.6 

0.5 

0.7 


Balance in favor of 
increase of weight 


542.1 


456.1 

28.1 


23.5 
6.0 


50.9 
2.9 


1.1 

0.9 


465.4 
17.9 


1.2 
0.4 



The student may thus see that the loss of weight during the first 
few days is considerable. It has not as yet been accurately deter- 
mined whether an infant nursed from the first day of life on a breast 
secreting abundant milk would lose weight similar to that of the 
newborn nursed on the mother's breast. It is well known that 
the loss of weight is greater in those fed on a substitute than 
on the breast. The further details of loss and increase of weight 
will be found under the heading of Infant-feeding. 



II. MORTALITY AND SUDDEN DEATH IN THE NEWBORN. 

Sudden death is not uncommon in the first week of life, and, 
according to Snow, fully one-tenth of the race succumb in the first 
month of existence. Modern methods have tended to reduce this 
startling mortality, but the conditions attending the birth of the 
infant are such that there will always be, independent of sepsis of 
any kind, a quota of the newborn Avhich will succumb, either with 
previous symptoms or suddenly, in the first w^eek or first month of 
existence. Eross has found that 9 J per cent, of all children born in 
Europe died in the first four weeks of life. Of these 37 per cent. 



172 THE DISEASES OF THE NEWBORN. 

died in the first week, 29 per cent, in the second, 21 per cent, in the 
third, and 13 per cent, in the fourth week. 

The statistics of the different countries vary, as one would natu- 
rally expect, according to the methods of midwifery in vogue. It 
is of interest, however, that, in the United States, Snow, of Buffalo, 
has collected some statistics on this subject in his own city. Of 
7290 births 471 died during the first month. Thus 6.4 per cent, 
of all the children born in Buffalo died during the first four weeks, 
a death rate of 9.3 per cent, of the total mortality. 

If we look for the causes of mortality in early life we may class 
them grossly under those due to (1) immaturity or congenital weak- 
ness, with or without syphilis ; (2) malformations which are fatal in 
themselves ; (3) asphyxiation and atelectasis ; (4) injuries sustained 
during parturition, such as apoplexies, both cephalic and abdominal ; 
(5) septic infections of various kinds. The effect of prolonged and 
difficult labor, abnormal presentations, the application of forceps, 
may cause a cerebral hemorrhage, especially in premature or congen- 
itally weak inflmts, but a difficult labor is not necessarily an etiolog- 
ical factor in these cases, for cerebral hemorrhages occur in infants 
who have passed through an apparently normal, or even a precipi- 
tate, labor. It seems that in these cases simple pressure of the parts 
in the parturient canal ])recipitates a hemorrhage which, subsequent 
to birth, attains an extent which is fatal. 

Spencer found that of 130 infants dying in the first few hours of 
life, 65 per cent, of deaths were due to injuries sustained by the 
brain in the form of congestion and hemorrhages, and he considers 
the forceps, next to abnormal presentations, such as foot and breech, 
as the most frequent etiological factor in producing hemorrhage. 

Hemorrhage and aj)oplexies of fatal character may occur in the 
liver, suprarenal capsule, and lung, and many children subject to 
cerebral hemorrhages succumb to convulsions in the first hours of 
existence. It must not be forgotten, however, that the most trying 
cases of sudden death in the newborn are those in which infants 
have been born after a labor in every respect normal, and who at 
birth presented absolutely nothing abnormal physically to the care- 
ful and practised eye, and who have continued in apparent health 
for twenty-four hours to a week, with sudden death as an out- 
come. These cases present absolutely no symptoms to warn the 
physician of the approaching catastrophe. They may nurse in a 
regular manner, apparently, the bowels may appear natural in color 
and consistence, and even after the death of the infant an inquiry 
into the clinical history of the case fails to reveal any symptom 
which might have led to the detection of the trouble. These cases 
postmortem may reveal a cerebral hemorrhage or an abdominal 
umbilical hemorrhage, which previously revealed but few symptoms. 
I recently saw such a case in a premature child, born rather precipi- 



MORTALITY AND SUDDEN DEATH IN THE NEWBORN. 173 

tately, which continued well and in perfect condition for twenty-four 
hours, then suddenly developed cyanosis, attacks of respiratory 
apnoea, and died within a few hours. In this case nothing was re- 
vealed postmortem but a slight atelectasis of the lung. Another, 
in w^hich an infant nursed on the breast of a wet-nurse for six days, 
did not lose weight, but rather held its own, nursed vigorously a few 
hours before death, cried but little, slept most of the time, and was 
found dead in bed, with a slight hemorrhage from the nose, on the 
sixth day. This, in all likelihood, was a case of unrecognized sepsis 
of the newborn. 

In the newborn all cases do not die suddenly. There is in most 
cases marked or slight warning, extending over days or hours before 
the fatal issue. There may be signs of cerebral irritation, but these, 
as a rule, come on suddenly in severe cases. Some time, hours or 
days, after birth, the child may be attacked with cyanosis, it may whine 
or cry without apparent cause, there may be derangement of the 
respirations, irregularly slow pulse ; there may be a series of con- 
vulsions, which may end the scene or which may continue for days. 
Sometimes a slight hemorrhage gives rise to no symptoms at all 
until later in life, so that we cannot say that hemorrhage always 
causes death in the newborn, for this is contrary to experience. 

If meningeal heuiorrhage is preceded by the symptoms such as 
have been detailed, a diagnosis can be made, but in cases in which 
these symptoms are absent clinical diagnosis is impossible. As- 
phyxia, atelectasis, and compression of the cord cause a mortality of 
3.6 per cent, of the total nuuiber of deaths in the newborn. In 
congenital atelectasis there may have been an easy labor, but inherent 
weakness and immaturity of the respiratory muscles may cause im- 
perfect expansion of the lungs. 

A large proportion of deaths in the newborn infant are the result 
of sepsis. The pathogeny and symptomatology of sepsis will be 
considered under the proper heading, but some of the severest forms 
of sepsis, resulting in arteritis of the umbilical arteries or in a 
general bacterial invasion, give absolutely no symptoms and 
result in sudden death. The conditions at this time of life are 
particularly favorable, as has been repeatedly pointed out in these 
pages, to the invasion of germs, and the avenues of infection are 
various, as has been dilated upon in the chapter on Sepsis in the 
Newborn. Not only is the resistance almost nil, but the progression 
of the disease is unhampered by such conditions as leucocytosis, which 
obtain later in life, for lack of leucocytic reaction and deficient de- 
velopment of the lymphatic apparatus is especially characteristic of 
this period of life. 

In addition to sepsis, sudden death in the newborn may be due 
to forms of respiratory disease, such as bronchitis and pneumonia, 
which have not only escaped observation, but which give absolutely 



174 THE DISEASES OF THE NEWBORN. 

no symptoms before the fatal issue supervenes, and are only revealed 
on the postmortem table. Such infections have been dilated upon 
elsewhere. They may originate in foul atmosphere, unclean bed- 
ding, aspiration of amniotic fluid, and as a result of this, contamina- 
tion by colon bacillus, staphylococci, and streptococci. We will not 
enlarge upon the other forms of sepsis of the gastro-enteric type, but 
will leave that for future consideration in the chapter on Sepsis. 
Sudden death in the newborn, due to hypertrophy of the thymus, 
is a great rarity. 



III. CONGENITAL ANOMALIES. 

Anomalies of the Scrotum. 

The scrotum may be divided into halves, separated com- 
pletely from each other, each with its contained testis. There 
are rarely more than two testes. There may be accompanying 
abnormalities, such as circumscribed hydrocele of the cord, lipoma 
fibrosum, and omental structures. Anorchidie is a condition of 
rudimentary or lacking testis and adnexa mostly unilateral. Ecto- 
pia testis abdominalis is a condition in which the testis is found 
underneath the skin of the abdomen. Ectopia cruralis testis is a con- 
dition in which the testis is found at the femoral ring, generally with 
a hernia. Ectopia perinealis testis is a condition in which the testis 
is found in the perineum. 

Retentio Testis : 

Retentio testis refers to those cases in which the testis remains in 
the abdominal cavity or in some part of the inguinal canal. 

Retentio abdominalis refers to the retention of the testis in the 
abdomen. 

Retentio iliaca, near the internal ring. 

Retentio inguinalis refers to the testis retained in the canal or 
near the external ring. 

Double retention is also called cryptorchism ; single retention is 
spoken of as momorchism. 

These congenital conditions are quite common in children, but 
disappear, as a rule, toward the age of puberty. The cause of the 
congenital anomalies is a lack of development or peritoneal adhe- 
sions, and their principal iuterest clinically lies in the fact that they 
may be confounded with hernia of an inguinal type. The retained 
testis of the inguinal variety is apt also to atrophy, inasmuch as it 
is easily exposed to traumatism. Kocher has shown, also, that it is 
more apt to be the seat of new growths, especially carcinoma. 

The diagnosis of retained testis, especially of the inguinal variety, 



HYDROCELE CONGENITA OB ADNATA. 175 

is not difficult. The mother will invariably call attention to the 
absence of the testis from its usual situation. Examination of the 
scrotum will reveal its absence either on one or both sides. By 
invaginating the scrotum through the inguinal canal, the physician, 
as a rule, will find the testis in some part of the canal or at 
the internal opening in the abdomen as a small globular body. 
Tracing the location of the testis, its absence from the scrotum and 
its presence in the abnormal position mentioned, differentiates it 
from a lymph node or a hernia. As a rule, hernia as a result of 
coughing or exertion, such as crying, Avill descend and increase in 
size or protrude from the external ring. Not so with the testis. It 
may even retract higher if pain is experienced. 

Treatment. — There is no treatment for this condition, although 
the French advise the systematic pushing down of the testis into the 
scrotum at certain intervals up to the age of puberty. 

Hydrocele Congenita or Adnata: 

This anomaly of the congenital type is caused by a lack of clo- 
sure of the peritoneal fold, the pars vaginalis peritonei. There is a 
communication of the cavity of the tunica vaginalis with the peri- 
toneal cavity to a greater or less extent. Serous fluid of the perito- 
neal cavity may gravitate to the cavity of the tunica vaginalis ; or 
there may be a free opening into the peritoneal cavity, allowing a 
reposition of the fluid. In such cases the anomaly is apt to be 
confounded with inguinal hernia. The communication with the 
peritoneal cavity may be of filiform size. 

The diagnosis from hernia is made possible by the fact that in the 
latter reposition with intestinal gurgle is possible ; whereas a hydro- 
cele cannot be reduced unless there is an opening through to the 
peritoneal cavity. On gentle percussion a hernia will also give 
tympany. Hernia will increase in size as a result of coughing or 
crying. Congenital hydrocele may disappear spontaneously. Irreg- 
ular adhesions in the canal may result in small collections of fluid 
along the course of the spermatic cord, thus forming hydrocele of 
the cord. When there is a communication of the peritoneum with 
the tunica vaginalis, a large hernia may result. 

The diagnosis of hydrocele of the cord in the young infant is 
often required of the physician. In these cases we find a collection 
of fluid around the cord in its course from the peritoneum to the 
testis. This fluid, however, does not communicate with the cavity 
of the tunica vaginalis testis ; nor can the fluid be replaced, as the 
hernia can, into the abdominal cavity. The fluctuating swelling 
extends from the testis to the external abdominal ring. 

Treatment. — -The treatment for congenital hydrocele or hydrocele 
of the cord is that of repeated puncture and withdrawal of the fluid. 



176 THE DISEASES OF THE NEWBORN. 

No irritants of any kind should be used in congenital forms of 
hydrocele, inasmuch as peritonitis may result should any anomalous 
opening into the peritoneal cavity exist. 

IV. THE CONGENITALLY WEAK (Premature Infants). 

Infants are congenitally weak who weigh less than 2000 grammes 
(41 pounds), have a body-length of 42 centimetres, and who, on 
account of a lack of development of the various organs and a 
consequent imperfect performance of their functions, show a dimin- 
ished vital energy. Such infants may be premature, w^igh as 
little as 600 grammes (1 J pounds), with a body-length of 21 centi- 
metres, and still live. As a rule, however, any infant weighing 
less than 1000 grammes (2.2 pounds) cannot live. The tem- 
perature must also be considered in the study of the congenitally 
weak, as wtII as the body-w^eight, for not only does this factor influ- 
ence the prognosis, but also the management of these cases. Con- 
genital weakness may thus exist to various degrees. 

Etiology. — Prematurity is a most frequent cause of congenital 
weakness. The early interruption of pregnancy may occur in 
apparently healthy mothers as a result of mechanical influences, 
intercurrent infectious disease, diseases of the placenta or uterus, or 
constitutional disease. Congenital weakness may exist in one of 
twins or triplets, the other infants being born strong and \\e\\ 
developed. Though most frequently found among premature in- 
fants, congenital weakness may exist in infants born at full term, as 
a result of the debilitating influences of tuberculosis or syphilis in 
the mother on the development of the foetus. The congenitally 
weak are also found among infants who are born at full term, but 
in whom there has been for some reason no complete expansion of 
the lungs and in whom atelectasis results (asphyxia of the newborn). 
Thus, congenital w^eakness may at times go hand in hand with pre- 
maturity ; at others prematurity is not an essential factor. 

Morbid Anatomy. — Premature infants are underweight according 
to the degree of prematurity. The head is small and globular ; the 
pupils still show the pupillary membrane ; the skin is red and 
glistens ; the face is wrinkled ; wool-hair or lanugo covers the body ; 
nails are undeveloped; the external genital organs, the clitoris and 
nymphse, are prominent ; the brain is undeveloped ; the heart and 
vessels present foetal characteristics, such as an open ductus Botalli 
or foramen ovale ; the thyroid and thymus glands and the supra- 
renal capsules are large ; uric-acid infarctions are found in the kid- 
ney ; the intestinal structures and bones are undeveloped. 

The lungs show areas of bronchopneumonia with atelectasis ; on 
the surface of the lungs there are hemorrhagic areas resembling infarc- 
tions. In other words, there is hemorrhagic pneumonia due to 



THE CONGENITALLY WEAK. 177 

infection either by streptococci, staphylococci, bacillis coli communis, 
or pneumococci. The bronchial nodes may be enlarged and there 
may be pericarditis. The intestines, liver, and kidney, in addition 
to being undeveloped, may present lesions similar to those found in 
sepsis. Infections may remain local and limited to the point of 
entrance of the bacteria, or may become general. The portals of 
infection are solutions of continuity in the skin, mucous membrane 
of the gastro-enteric tract and respiratory passages which allow the 
entrance of bacteria from the air, garments, or objects brought in 
contact with the infant's hands, linen, or food. 

Symptoms. — The body is spare ; the skin is soft and delicate, 
uniformly red and transparent, showing plainly the bloodvessels. 
The delicacy of the skin renders it susceptible to traumatism, result- 
ing in the formation of erosions. The surface is cool, pale, icteric, 
sometimes cyanotic. Desquamation of the skin, present normally 
in the newborn, is delayed from four to eight weeks. In very 
severe cases there may be sclerema. 

The infant doos not cry, but rather whimpers ; the respiratory 
movements are scarcely noticeable, there is muscular inertia, and 
the infant lies in a torpid condition. The intestine and stomach 
are easily disturbed ; the liver performs its function imperfectly, 
and in many of these cases there is icterus. A temperature as 
low as 30° C. (86° F.) may exist and continue for days. These 
infants, if left exposed momentarily, even after a warm bath, 
may experience a serious reduction of temperature. They are 
thus easily chilled, and attain a temperature near the normal only 
with the greatest difficulty. The body-temperature during treatment 
in the incubator may not rise above 36.9° C. (98.4° F.). In those 
infants aifected with sclerema the temperature may not rise for days 
above 28° to 35° C. (82.4—95° F.) in the rectum. As a dire'ct 
result of the low body-temperature and disturbed metabolic pro- 
cesses these infants suffer from cyanosis, which at times is difficult 
to dissipate. 

There is at first a lack of nursing power, and at most 10 or 15 
c.c. of milk are taken at a nursing. The evacuation of the bowels 
takes place very sluggishly, often days apart ; meconium persists in 
the gut as long as six to eight days. The urine is passed in much 
diminished quantity, and the loss of weight is more rapid than is 
true of normal infants. 

Should a premature infant develop an infectious bronchopneu- 
monia, the diagnosis is extremely difficult. Percussion can rarely 
establish a dulness of any extent, the respiratory movements are 
feeble, the air scarcely enters the lungs, cyanosis is present, and the 
temperature may be subnormal. The infant will therefore simply fail 
in a general way. There may be an eruption or hemorrhages in the 
skin, and death may take place with general or partial convulsions. 



178 THE DISEASES OF THE NEWBORN, 

The congenitally weak infant may, if fed incorrectly, either with 
too much or faulty food (milk), suffer from diarrhoea, which tends 
not only to a reduction of body-weight, but to an increase of weak- 
ness. 

Prognosis. — The body-weight, the rectal temperature, and the 
mode of feeding determine the prognosis. 

Of the congenitally weak weighing less than 1200 grammes, but 
few or none are saved ; of those weighing 1200 to 1400 grammes, 
40 per cent, are saved; of those weighing 1500 to, 1599 grammes, 
86.7 per cent, are saved ; and from 2000 to 2500 grammes, 93.6 
per cent, are saved (Budin). 

As an exceptional instance of successful rearing of the congeni- 
tally weak may be mentioned the case of Villemin, who records the 
saving of an infant who at birth weighed only 955 grammes (2 
pounds). 

The influence which the rectal temperature has on the prognosis 
is shown by Budin, who found that of cases weighing less than 1500 
grammes, with a rectal temperature of 32° C. or less, only 2 of 103 
were saved; of those weighing 1500 to 2000 grammes, with a 
rectal temperature of 32° C, only 1 of 39 was saved: a combined 
mortality of 98 per cent. Therefore the rapid reduction of tem- 
perature is an important factor in the mortality of these infants. 

The mode of feeding is an important element in the prognosis, 
for the mortality is greater among the congenitally weak or prema- 
ture infants brought up on the bottle than among those reared on the 
breast. 

It is interesting to note the observation of Budin, that of 54 
infants who had at departure from his service weighed 2800 to 3000 
grammes, 31 per cent. died. Of the 54 infants, 24 were fed arti- 
ficially, of whom 41 per cent, died ; of 20 fed at the breast, only 
15 per cent. died. 

The causes of death among the congenitally weak, when brought 
up by methods to be described hereafter, are principally infectious 
bronchitis, bronchopneumonia, infectious and epidemic disease. 
Aside from infectious diarrhoea, syphilis and digestive disorders 
play an important role as causes of death. 

Management of Congenitally Weak Infants. 

In speaking of the management of congenitally weak infants the 
student should understand that each country has its favorite method 
of managing these cases ; and it may be stated at the outset that we 
may well copy the methods of the French, who have made a very close 
study of the art of saving the premature and congenitally weak. 
If a premature or congenitally weak infant is born asphyxiated, the 
treatment is much the same at the start as that detailed in the sec- 



MANAGEMENT OF CONGENITALLY WEAK INFANTS. 179 



tion on asphyxia of the newborn ; but, as intimated, our efforts 
must be directed to saving the congenitally weak, after resuscitation 
methods have succeeded, by maintaining the body-temperature, by 
feeding the infant correctly, and by supporting the heart and respira- 
tion. The weight and the rectal temperature, therefore, not the age 



Fig. 24. 




Lion incubator. 



of the infant at birth, will decide for the most part the line of treat- 
ment, for some infants at full term, as has been stated, are much 
below the normal weight, with a subnormal temperature, and are 
therefore congenitally weak. It would be unsafe to outline any 
treatment based only on the age of the infant at birth. 



180 



THE DISEASES OF THE NEWBORN. 



Wo will first take up the methods of niaintainlng the body-tem- 
penitiire. This is done by means of the incubator. 

Incubators. — Tlie simplest model of an ellicient incubator for 
maintaining the temperature of the conirenitally weak is that first 
introduced by Tarnier. Though many com})licated })ieces of appa- 
ratus have been constructed since the time of this clinician, none has 
surpassed his model in effuueney. The most eflieient incubators are 
made of metal or are ])orcelain-lin(Hl, sim])le in construction, and 
allow of thorough ventilation while maintaining the desired degree 
of temperature. Infections being connnon at this period, an incu- 
bator should be so constructed that it can be easily cleaned and 
subjected to sterilization before use. Incubators made entirely of 
wood are therefore useless, if not dangerous. 

Of the elaborate incubators that of Lion (Fig. 24) has given the 
greatest number of successes. This elaborate ap])aratus can be well 

Fig. 25. 




Simple form of baby incubator 



ventilated and equably heated. The heat is su])])lied by radiation. 
The cheaper forms of incubators are constructed from models of the 
form which is used in the Sloan Maternity Hospital in New York 
City (Figs. 25 and 26). In an emergency, any kind of tin-lined 



MANAGEMENT OF CONGENITALLY WEAK INFANTS. 181 

box or a basket padded with cotton, supplied with warmiDg bottles, 
and so protected on top as not to admit of a too rapid escape of the 
air, answers the purpose of a more elaborate apparatus. In fact, 
Chapin has shown that with very elaborate apparatus he has had less 
brilliant results than with simpler means. The cause of his ill-suc- 
cess lies in the fact that complicated apparatus is very difficult to 
cleanse after having once been infected. 

The indications for the employment of any form of incubator 
are : (a) Weight, the infant weighing 2000 grammes or less. Infants 
weighing 1800 grammes, if vigorous, may be reared without an 



Fig. 26. 



THERMOMETER 



THERMOMETER 




FUNNEL 
FOR FILLING 






WINDOW 




TANK 


'^~^ 


/^ 









ERESU AIR PIPE 



Plan of simple form of incubator. A, B, water tank heated by lamp ; in this tank are 
the fresh-air pipes. The air is heated before passing into the top' section, in which the 
infant lives. 



incubator, (b) Subnormal rectal temperature, as has been empha- 
sized elsewhere, (e) Cyanosis or sclerema. 

The temperature at which the interior of the incubator should be 
maintained is of the greatest importance. It has been customary to 
keep the temperature of the interior of the incubator a little higher 
than that of the infant, with the idea that in this way the heat 
which is transmitted to the body of the infant is necessary. Later 
investigations have proved that an infant with a rectal temperature 
of 30°-32° C. (86.6° to 89.6° F.) will be more comfortable and 
thrive better in an incubator kept at 25°-26°C. (77° to 78.8° F.) 
than in one in which the temperature is 35°-37° C. (95° to 98.6° F.), 



182 



THE DISEASES OF THE NEWBORN. 



Fig. 27. 



as was formerly practised. Therefore the interior of the incu- 
bator should have a temperature of 25° to 26° C. (77° to 79° F.). 
An infant brought up in an incubator should increase regularly in 
weight and strength. It should have one or two movements daily, 
and should take its nourishment at regular intervals. If it loses 
in w^eight, remains cold, cannot be roused, breathes superficially, 
develops cyanosis, dyspnoea, diarrhoea, cough, or vomiting, the outlook 
is grave. Even should the infant thrive, it must not be allowed to 
remain torpid. It should be taken out of the incubator cautiously, 
and, if the respiratory movements are shallow, should from time to 
time be caused to cry by mild irritation. In this way the lungs are 
expanded and become aerated. The infant should be turned on its 
side and kept lying in that position, thus avoiding hypostasis in the 
lower or posterior part of the lungs. If vomiting occurs, the food 
should be modified, peptonized, or reduced in quan- 
tity, or the intervals of feeding lengthened. Cyan- 
osis, as has been mentioned, is met by friction and 
flagellation. In carrying this out caution must be 
observed as regards the liver, which is quite large 
at this period and easily lacerated. If mucus collects 
in the throat, it must be cautiously aspirated by 
means of a small rubber catheter introduced to the 
back of the pharynx, passing over the epiglottis to 
the superior opening of the larynx. Success in feed- 
ing will also aid in overcoming the cyanosis. 

Feeding. — The feeding of premature infants is a 
most difficult problem. At this time, as a rule, the 
infant is unable to grasp the breast. Therefore it 
must be fed with a pipette or a nursing tube con- 
structed for this purpose (Fig. 27). In these cases 
the milk is pumped from the breast and transferred 
to the infant. We must be careful not to give too 
much food, for thereby diarrhoea and vomiting may 
set in ; on the other hand, too little food will only 
tend to perpetuate the weakness and cause cyanosis. 
During the first ten days there may be loss of weight, 
or the weight may remain stationary and finally in- 
crease. Budin found in feeding these infants that 
there were three sets of cases, in each of which he 
could estimate the amount of food taken daily. 
In the first set of cases the infants weighed less 
than 1800 grammes and on the second day took 115 grammes 
of nourishment ; on the tenth day, 320 grammes. The second set 
of cases were those which ranged from 1800 to 2200 grammes, 
and on the second day took 128 grammes of breast milk; on the 
tenth day, 410 grammes. The third set of cases weighed from 



e; 



Breck's feeding 
tube for prema- 
ture infants. 



THE CONGENITA LLY WEAK. 183 

2200 to 2500 grammes, and on the second day took 180 grammes 
of milk ; on the tenth day, 425 grammes. Thus, the amount of 
food will vary with the weight and must be gradually increased in 
all cases. A small quantity (see Infant-feeding) must be given at 
each feeding, and the feedings should be at intervals of one and a 
half hours. 

Feeding by gavage instead of by the pipette was first resorted to 
by Tarnier. It may be said, however, that this is scarcely necessary 
except in very torpid infants. 

We must be exceedingly careful in institutions, in caring for pre- 
mature infants, to guard against the spread of any form of disease 
which may attack them. A bronchitis in a premature infant is a 
more serious disease than in an infant born at full term with normal 
weight and temperature. This bronchitis is of the infectious type 
and very fatal to premature congenitally weak infants. As a rule, 
it leads to bronchopneumonia, and in institutions is apt to spread 
from one weakling to the other. Any epidemic disease may attack 
these infants ; prophylaxis therefore plays an important role in 
the prognosis. In institutions a congenitally weak infant attacked 
with bronchitis should immediately be isolated as in any other infec- 
tious disease. In private practice visitors should not be allowed to 
see these congenitally weak infants and thus infect them. Anyone 
suffering with an ordinary cold should be forbidden to come in the 
vicinity of an incubator. 

Bosi, Giudi, Escherich, and others have proposed the construction 
of incubator wards, in which the infant should not be exposed to 
the changes of temperature and danger of infection when taken out 
of its crib. It may be stated, however, that there is a great dis- 
advantage in the construction of incubator wards, for neither can 
infections be avoided any more than in ordinary hospital wards, nor 
can the temperature in a large space be maintained as easily as in 
small chambers ; and, finally, the isolation of one little patient from 
another cannot be as complete in an incubator ward as in the indi- 
vidual crib or incubator. 

Bath and Clothing of the Congenitally Weak. 

The congenitally weak or premature infant is easily chilled, and 
therefore after birth should not be bathed. It should be well 
anointed with oil, and this removed with absorbent cotton in such a 
manner that the body is left clean and free from vernix caseosa or 
extraneous substances. The infant is then wrapped in one layer of 
sterilized cotton covering the trunk and the extremities. Over this 
is sewed a jacket of sterile gauze so as to encase the whole body. 
The buttocks and genitals, however, are left free, so that any meco- 
nium or urine that is passed may be caught by cotton placed against 



184 THE DISEASES OF THE NEWBORN. 

these parts. In this way the infant is not chilled when taken from 
the incubator to be fed or washed. 



Ultimate Fate of the Incubator Infant. 

Some of the best developed men and women came into the world 
congenitally weak, so that the physician should spare no effort to 
bring about success, no matter how weak the infant may appear at 
the outset. Especially encouraging are the results obtained with 
the congenitally weak when it has been possible to feed the infant 
from the beginning to the termination of infancy with breast milk. 
The statistics of Budin, quoted elsewhere, show conclusively that 
of the premature infants discharged from his institution with a 
weight of 2800 to 3000 grammes, those who fared best were the 
breast-fed infants, of whom only 15 per cent, died before attaining 
maturity, whereas 41 per cent, of the bottle-fed infants died during 
infancy. 

The physician will have an easier task if, in addition to the incu- 
bator, he makes every effort to obtain human milk for the weakling. 

Feeding of the Congenitally Weak and Premature Infants. 

Breast-feeding. — The ideal method of feeding the congenitally 
weak, and the one which is attended with the greatest number 
of successes, is that with breast milk. There are, however, some 
facts which must not be lost sight of in feeding the congenitally 
weak on the breast. Their suction power is much below that of the 
normal infant born at full term. In some cases the congenitally 
weak infant is unable to nurse at all. If the mother and not a 
wet-nurse is to nourish the infant, the milk must be pumped from 
the breast and fed to the child by means of the Breck Feeder, if 
the infant is unable to nurse the breast directly. In extreme cases 
the infant will not even have the power to swallow the milk pumped 
from the breast and fed to it w^ith a feeder. Under such circum- 
stances the milk must be carefully fed to the infant, by means of 
gavage, four or five times in the twenty-four hours. As a rule, 
however, the mother of a premature infant will, if the infant is born 
much before full term, have very little milk in her breast. In such 
a case, it is advisable to obtain a wet-nurse whose milk is uniform, 
and whose child is at least one or two months of age. Should a 
wet-nurse not be available at this time, the infant may be placed on 
modified milk until the milk appears in the mother's breast. A 
wet-nurse who nurses a congenitally weak infant exclusively will 
lose her milk gradually, because the congenitally weak infant, though 
it nurses the breast, exerts so little suction power that the normal 
excitation to continued glandular activity of the breast is lacking 



FEEDING CONGENITALLY WEAK AND PREMATURE INFANTS. 185 

and the milk gradually diminishes in quantity, finally ceasing to be 
secreted. It is well, therefore, to allow the wet-nurse to nurse her 
own infant while supplying the excess of milk to the congenitally 
weak infant she is caring for. Under this arrangement there need 
be no fear that either infant will suffer from an insufficiency of milk, 
inasmuch as the additional stimulus given by the two infants to the 
gland will result in an increased secretion of milk, a fact which has 
been repeatedly proved. 

The amount of breast milk which a congenitally weak or prema- 
ture infant will take from the breast will vary widely with the 
strength, age, and weight of the infant. As a rule, the amount will 
vary from 200 to 500 c.c. daily. The nursings should be at inter- 
vals of an hour to an hour and a half. The younger the infant the 
more frequent should be nursings and the smaller the quantity at 
each feeding. If the infant is unable to nurse the breast, the milk 
may be pumped off and given in a bottle or feeder to the infant ; or 
is given, as has been stated, by gavage. It may happen, as has been 
intimated, that the mother, after the birth of a premature infant, has 
very little milk in her breast. If such an infant is placed tempo- 
rarily on modified milk, the milk may appear in the mother's breast 
after a week or two, and the gland may be excited to increased 
secretion by placing the infant at the breast, especially if it be not 
too premature or weak. 

Artificial Feeding. — The feeding of the congenitally weak or 
premature infant with modified milk is a very difficult task, inasmuch 
as comparatively few facts are at our disposal to-day as to the success 
of this mode of feeding. We know that the success attending the 
feeding of the congenitally weak or premature infant on cows' milk is 
even less than that of feeding the normal newborn infant. We will 
illustrate the feeding of these infants by taking as an example a 
premature or congenitally weak infant born at seven and a half 
months of pregnancy. Such an infant is first placed upon a mixture 
containing 1 per cent, of fat, 0.25 per cent, of proteids, and 5 or 6 
per cent, of sugar. The infant is given 10 c.c, or 2 J drachms, at 
each feeding, the intervals between the feedings being one hour. 
Twelve feedings are given in the twenty-four hours, rest being 
given for the remaining twelve hours. 

After a week of extra-uterine life the percentage of proteids is 
doubled, the fat and sugar remaining the same. From the fifteenth 
day of life the infant will be taking J ounce at each feeding, tw^elve 
feedings being given in the twenty-four hours. After the fifteenth day 
the proteids may be increased, so that from the thirtieth day of life the 
infant will be taking a mixture of 1 to 1.5 per cent, of fat, 0.75 per 
cent, of proteids, and 6 per cent, of sugar, IJ ounces at each feeding, 
with intervals of two hours between the feedings. Ten or twelve 
feedings are given in the twenty-four hours. At this time the infant 



186 THE DISEASES OF THE NEWBORN. 

will have approached the age of a fall-term infant. We should 
now be cautious not to increase the percentages or strength of the 
mixture too rapidly, but rather to let them remain stationary and 
watch the increase of weight. If the weight increases along physio- 
logical lines, we are then guided by the same considerations which 
would obtain with an infant born at full term. 

Congenitall}^ weak infants, fed upon modified milk mixtures, who 
show dyspeptic disturbances, evidenced by green stools or white 
curds in the movements, should a wet-nurse be unavailable, are fed 
with a peptonized mixture. The peptonizing is carried out with 
good results by the process detailed elsewhere. 

Mixed Feeding. — This is a combination of breast and bottle- 
feeding in those cases in which the breast does not yield sufficient 
milk and the weight of the infant remains stationary. This is seen 
in cases of twins nursed by the mother or even by a wet-nurse. In 
such cases several feedings by means of the bottle may be given 
daily in addition to the breast. 

The Amount of Food Taken by the Congenitally Weak 
Infant Daily. — It has been shown conclusively that the congenitally 
weak infant at the breast will consume daily approximately one-fifth 
of its own weight of breast milk. The so-called normal quantities 
of breast milk taken by the congenitally weak infants, carefully 
weighed before and after nursing, are found by Budin to be as 
follows : 

Infants of 1000 gi-ammes, 200 grammes, 
1500 ^' 250 
" 1800 " 360 

" 2000 " 400 

'' 2500 '' 500 

" 3000 " 600 " 

The amounts of breast milk taken daily in the first ten days of 
life gradually increase, as stated, from 115 grammes, taken the 
second day by an infant of 1800 grammes, to 320 grammes on the 
tenth day. An infant weighing 2200 to 2500 grammes will take 
on the average 180 grammes, taken the second day, to 425 on the 
tenth day, its normal quantity of food. 

These quantities of breast milk consumed by the congenitally 
weak will be seen to exceed or equal in amount what the normal 
infant at full term consumes. This proves distinctly what has 
always been insisted upon by the writer that the amount of food 
necessary to the infant is determined by the needs of the body and 
not by any arbitrary standard of stomach capacity. In other words, 
the congenitally weak infant, though under weight, really needs 
more calories of foodstuffs per kilogramme of body-weight than the 
full-term infant, because it uses up more heat units of energy, 
having more extent of body surface exposed for its weight than the 



ASPHYXIA OF THE NEWBORN INFANT. 187 

normal full-term infant. Unless the calories, in the form of in- 
creased nourishment, are supplied to these congenitally weak and 
premature infants, they fail to thrive, become cyanotic, and die. 
Thus, when feeding these infants with cows' milk, modified or pep- 
tonized, it must not be forgotten that the above principles hold true, 
and that the amount of breast milk consumed by the congenitally 
weak is a better guide as to the necessary quantity of artificial food 
to be given these infants than the weight or stomach capacity. On 
the other hand, if the congenitally weak are fed in excess of their 
needs, there result vomiting and diarrhoea with loss of weight or 
stationary weight. 

V. ASPHYXIA OF THE NEWBORN INFANT. 

Definition and Etiology. — Asphyxia is a condition produced by 
an interference with the oxygenation of the blood. In the uterus 
respiration is effected through the placenta. If the placenta is sep- 
arated wholly or in part from its uterine attachment, or the circula- 
tion in this organ is interfered with, the disturbance of the normal 
conditions causes efforts at respiration, the result of deficient oxy- 
genation of the blood. Asphyxia may thus be produced by tonic 
contraction of the uterus, premature rupture of the membranes and 
escape of the liquor amnii, asphyxiation of the mother, a hemor- 
rhage, the administration of drugs to the mother intra-partum, pres- 
sure on the cord, injury to the head intra-partum, or through 
pressure on the vagus intra-partum, with disturbance of the respira- 
tory centres. If the placenta is separated prematurely there are 
consequent efforts at respiration, during which liquor amnii or mucus 
may be aspirated and asphyxia thus produced. In the extra-uterine 
form of asphyxiation the infant is born and makes efforts at respi- 
ration ; but inherent constitutional weakness, weakness of the res- 
piratory muscles, deformity of the chest, or disease of the lungs 
renders full expansion of the lungs impossible. Syphilitic disease 
of the lungs, tumors of the lungs, or affections of the pleura may 
have the same effect. 

Morbid Anatomy. — The blood in infants who have died asphyxi- 
ated is thin and fluid. The right heart and large vessels are filled 
with blood, as are also the sinuses of the dura mater, pia mater, and 
liver. The liver is dark and bluish in tint. Punctate hemorrhages 
are found in the pia mater, pleura, pericardium, peritoneum, liver, 
kidney, retroperitoneal connective tissue, uterus, kidneys, suprarenal 
capsule, and retina. There is a serosanguinolent effusion into the 
cavity of the peritoneum, pleura, and pericardium. Ql^dema of the 
extremities, scrotum, and connective tissue aHout the umbilical ves- 
sels and pia mater is present. The lungs are dark red and heavy. 
Ecchymoses are seen underneath the pleura and pericardium. In 



188 THE DISEASES OF THE NEWBORN. 

the lungs there are islands of aerated tissue and areas of atelectasis, 
even though the infant has breathed. The trachea and bronchi may 
be filled with liquor amnii, mucus, or meconium ; the latter is recog- 
nized by the presence of lanugo, epithelial scales, fatty crystals, bili- 
rubin, and cholesterin crystals. The stomach may be filled with air 
or meconium. 

Symptoms. — If in a normal state when born, the infant breathes 
energetically, cries lustily, and opens its eyes, and the skin, which is 
of a purple hue at first, rapidly assumes a pinkish tint. If asphyxia 
be present, however, we may have two sets of symptoms, which are 
characteristic of two forms of this condition. 

In the first form, or early stage, of asphyxia, the skin has a 
bluish or pinkish-blue tint. The face is swollen and the conjunctivae 
injected. The infant does not move the extremities. The muscu- 
lature retains its tonicity ; the heart action is slow but forcible ; the 
apex beat is apparent to the eye ; the vessels of the cord are filled 
with blood and pulsate ; the respiratory efforts may be shallow and 
infrequent, or absent ; the infant can be roused and caused to cry. 

In the more advanced form of asphyxia the face is pale and 
waxy, the lips are cyanosed ; the extremities hang lax, and the mus- 
cular tonus is absent ; the head falls to one side and the jaw drops. 
There is no attempt at respiration or only imperfect gasping efforts. 
The infant has a corpse-like appearance. The heart-beat is weak 
though palpable. The vessels of the cord are collapsed and pulsa- 
tion is weak. If a few gasps of respiration are made at birth, these 
soon cease. On attempt at respiration the ribs are retracted, but the 
muscles of the face are immobile. Air is prevented from entering 
the lung by the inspired mucus. The reflexes are absent. If un- 
treated, infants in this stage of asphyxia die. If they live, efforts 
at respiration must be repeatedly encouraged, else the infants relapse 
into a torpid condition and the respirations become superficial. 

Diagnosis. — Asphyxia must be differentiated from the effects of 
pressure due to cerebral hemorrhage occurring at birth during a pro 
longed labor or application of the forceps. In a large hemorrhage 
death is rapid, but in slight hemorrhage it may be difficult to make 
a differential diagnosis. If there is a hemorrhage on the surface of 
the brain, the symptoms may closely resemble those of asphyxia. 
The breathing is very superficial ; the infant lapses into sopor ; the 
pulse may at first be slow and subsequently rapid. There may be 
occasional convulsions. The fontanelle in cases of hemorrhage on 
the surface of the brain has a peculiar hard feel. The subsequent 
history only will clear up these cases. Asphyxia may be combined 
with cerebral hemorrhage. The history of the birth as to the use of 
forceps and the duration of the labor will aid us. If after irritation 
the infant relapses into sopor, if the pulse continues slow and there 
are repeated convulsions, we may assume the existence of hemorrhage. 



ASPHYXIA OF THE NEWBORN INFANT. 189 

The prognosis in all forms of asphyxia, if untreated, is grave, 
and in the second stage is necessarily fatal. If treated, however, 
the majority of these cases recover, especially those in the first stage. 
As to the cases of the second stage, much will depend on the dura- 
tion of the second stage of labor and the compression of the cord. 
The cases in which cerebral hemorrhage of any severity is combined 
with the asphyxia are grave. Little and Mitchell have demonstrated 
that idiocy may subsequently develop in these cases. 

The treatment of asphyxia is directed to clearing the air-pas- 
sages as much as possible of obstructing mucus, increasing the num- 
ber of respirations, and stimulating the circulation. The mucus and 
aspirated meconium are quickly but gently removed from the mouth 
by the finger. 

An instrument has been devised for the aspiration of mucus 
from the upper part of the larynx and trachea ; but this instru- 
ment is not always at hand, and a sterilized catheter, No. 7 
French, can be easily introduced to the rima glottidis, and the 
mucus thus aspirated by means of mouth suction. Care, of 
course, must be taken by the nurse or physician not to infect the 
catheter. To avoid this a small piece of glass tubing may be 
attached to the distal end, and in the lumen of the tubing a small 
piece of cotton may be loosely plugged ; thus saliva and bacteria 
from the mouth will not enter the catheter. Introduction of the 
catheter into the trachea is hardly necessary. 

In order to stimulate the surface, the infant is quickly placed in 
a bath at 40.5° C. (105° F.), and then in a cold bath, thence trans- 
ferred to a warm blanket and rubbed thoroughly dry. After this 
the infant is, if possible, roused by striking the buttocks quite 
sharply. If these methods do not cause the infant to cry and 
breathe deeply, artificial respiration by the Schultze method should 
be resorted to. The operator, standing with his body well balanced, 
grasps the infant by the shoulders, the thumbs being on the anterior 
aspect of the thorax, the index fingers in the axillae, and the other 
fingers on the back of the chest. The head is supported by the 
ulner side of the wrists. The operator allows the infant to hang 
down from his hands between his legs. The infant is then raised 
or swung upward above the level of the operator's head to the ver- 
tical, so that the lower part of the trunk of the infant is bent on the 
thorax. The thorax is thus compressed, causing passive expiration. 
The infant is held for an instant in this position, and then swung 
down to the original hanging position. Passive inspiration is thus 
performed. 

The Schultze manoeuvre should be repeated at the rate of about 
ten times a minute, at intervals of several seconds. Care must be 
exercised not to injure the thorax by pressure of the thumbs or the 
other fingers, the infant being swung on the index fingers. After 



190 THE DISEASES OF THE NEWBORN. 

applying the Schultze method as above for a few minutes the infant 
is given a warm bath, and, if respiration is not completely estab- 
lished, the swingings are repeated. By this method the bronchi and 
mouth are freed from mucus, meconium, and liquor amnii, if present. 
The Laborde method is that by which traction is made on the tongue 
ten on twelve times a minute. The infant is laid on a flat surface 
with a folded towel placed between the shoulders, and the tongue is 
rhythmically drawn forward by means of a forceps and allowed to 
recede a number of times, corresponding to the normal number of 
respirations. 

The mouth-to-mouth method consists in first clearing the upper 
air-passages of mucus. The operator then forcibly blows into the 
mouth of the infant. The chest of the infant is then compressed 
to force out the air (expiration of the infant). This procedure is re- 
peated as often as sixteen times a minute. 

The Dew method seeks to accomplish the same result as the 
Schultze method, but by simpler means. The infant is grasped by 
the one hand at the nape of the neck, and by the other hand at the 
knees. The thighs rest in the palm of the hand. The thorax is 
flexed on the abdomen, and then extension is performed. Alternate 
expiration and inspiration take place. Inflation of the lungs by 
means of instruments introduced into the larynx is dangerous. 
There are other methods of artificial respiration which may be 
resorted to, such as the Marshall-Hall method, but, on the whole, 
the Schultze procedure seems the most effective. 

The danger in all cases is in abandoning efforts at resuscitation 
too early. We should persist in our efforts as long as the heart 
action continues. After the infant has been brought out of the stage 
of severe asphyxia there is always danger of relapse into a soporous 
state. In this condition flagellation on the buttocks at regular in- 
tervals may be necessary for days. 

In some cases, even after resuscitation has taken place, mucus 
will continue to collect in the upper air-passages. In other words, 
on account of cardiac weakness there is a persistent pulmonary 
oedema. In such cases tracheal mucus will collect in the upper part 
of the glottis, and I have seen brilliant results follow the occasional 
introduction into the upper part of the glottis of the catheter for the 
removal of this mucus by means of suction. I have made use of 
this procedure at very short intervals throughout the twenty-four 
hours with excellent results. 

In cases of asphyxia the after-treatment is as important as the 
immediate measures. The infant must be constantly watched. If 
the respirations become too shallow, the infant is gently flagellated ; 
and when mucus collects in the throat, it is removed. 

One of the best drugs to help us with these weakly infants is the 
ammonium carbonate (J grain) given every two hours, with or with- 



ASPHYXIA SUBSEQUENT TO BIRTH. 191 

out strychnia sulphate (5 J-oth of a grain every three hours). The 
infant must be kept warm and carefully fed. Some of these infants 
will not nurse, either on account of inherent weakness or paralysis 
of the tongue, caused by pressure of the forceps, and much patience 
must be exercised. If the tongue has been injured or the hypo- 
glossal nerve pressed upon during birth, one side of the tongue may 
be deflected, and at each feeding the food may find its way into the 
upper part of the glottis, causing spasms of coughing and cyanosis. 
In these cases the nurse will discover that the infant can be fed in a 
certain posture more successfully than in another, or with a pipette 
instead of the nursing bottle. If the cyanotic attacks are frequent 
oxygen must be given almost continuously for hours. After being 
worked over for days, such infants may make a good recovery or 
die and show extensive atelectasis in spite of the fact that respiration 
has occurred. 



VI. ASPHYXIA SUBSEQUENT TO BIRTH. 

In these cases there is no disturbance of the placental circulation 
previous to the birth of the infant, and therefore no asphyxia. 
Asphyxia appears after birth as a result of some abnormality in the 
respiratory apparatus or of disease of the lung, such as syphilitic 
hepatization ; of pleural exudate ; of compression of the air-passages 
by a struma ; or of defects of the diaphragm or deficient develop- 
ment of the lungs. In some cases there may have been injury or 
compression in the vicinity of the respiratory centre. 

Prematurity carries with it a pliable condition of the ribs and 
weakness of the respiratory muscles, an insufficient development of 
the respiratory centre, and foetal atelectasis, which give rise to a 
state of asphyxia. The more premature the infant the more pro- 
nounced are these conditions. 

Symptoms. — The infant makes no decided eflbrt at respiration 
after birth. Inspiration is absent or is hardly noticeable and shal- 
low. Rales are absent. The vessels in the umbilical cord are filled 
with blood and pulsate distinctly. The heart has a normal fre- 
quency at first ; then the contractions become slower and may event- 
ually be increased in frequency. The skin is bluish-red in color ; 
the extremities are cool. If there is any disease or deformity of the 
lung, the infant dies soon after birth. These cases are only of scien- 
tific interest. Of more importance to the physician is the prema- 
ture infant normal in all respects save in the fact of its expulsion 
from the uterus before term. 

Premature infants at the sixth, seventh, or eighth month are not 
all born debilitated, nor are all debilitated infants necessarily prema- 
ture. There are infants born at the eighth month which are as easily 
reared as an infant at full term. (See The Congenitally Weak.) 



192 THE DISEASES OF THE NEWBORN. 

VII. ATELECTASIS OF THE LUNGS. 

This condition has been referred to in the section on Asphyxia. 
Atelectasis, or collapse of the lung, may be congenital or acquired. 
In the congenital variety the infant is either weakly or born prema- 
turely. The respiratory muscles do not possess sufficient tonus to 
inflate the lung. The result is that the lung remains in the collapsed 
foetal state. In the acquired form the lung cannot expand, as a 
result of obstructions of the bronchi or alveoli, compression of 
the lung by an exudate in the pleura, deformity of the vertebral 
column, or aneurysm of the aorta. 

Etiology. — The lung at birth is compact, the alveoli being col- 
lapsed. The respiratory effi3rts inflate the alveoli, and the lung 
unfolds gradually, as described elsewhere. If after birth the res- 
piratory effi3rts are insufficient and the bronchi obstructed, or parts 
of the lung compressed or uninflatable, then a greater or less number 
of the lobuli remain uninflated and atelectasis results. 

If part of the lung which is functionating is thrown out of 
action from any cause, an acquired atelectasis results. This may 
result either from compression (compression atelectasis) or from 
obstruction (obstructive atelectasis). A bronchus may be closed or 
the alveoli may be filled with fluid masses. Atelectasis may result 
from an accumulation of fluid or air in the pleura, or from an 
inability of the diaphragm to act in consequence of curvature of the 
spine, aortic aneurysm, or contracture of the pleura with thickening. 

If the whole lung is involved, it is pressed against the spine, 
condensed and tough, devoid of air, of a pale-red color or pigmented. 
The areas of partial atelectasis have the same characteristics, but 
are redder and filled with blood. If a bronchus or bronchiole is 
obstructed, the lung collapses and returns to the foetal state. It 
becomes the seat of passive congestion, so that the atelectatic area 
is bluish-red in color. Obstructive atelectasis is quite frequent, 
and is seen accompanying any inflammatory process of the swollen 
bronchi. The bluish-red atelectatic areas are seen on the surface of 
the lung to alternate with the red areas containing air. Congenital 
atelectasis reveals portions of the lung as firm, non-crepitant, dark- 
blue, depressed areas with a smooth surface on section. These areas 
can be inflated, and then cannot be distinguished from the surrounding 
lung. Inflammatory atelectasis shows the same appearances. At 
autopsies on children dying of inflammatory disease of the lung, 
these areas of atelectasis • are seen more frequently the younger the 
subject. Rachitic children are especially subject to atelectasis, on 
account of their inability to inflate the lung completely. 

Symptoms. — The symptoms of atelectasis are not always clearly 
defined. As a rule, the infants, if premature, are weak ; their torpid 
state has been described in the section on the Congenitally Weak, 



ATELECTASIS OF THE LUNGS. 193 

On the other hand, should atelectasis develop some time after birth 
as a result of inflammation and plugging of the smaller bronchi, we 
shall have the combined physical signs of atelectasis, bronchitis, and 
possibly bronchopneumonia. In this class of cases the physical 
signs are as follows : 

Inspection. — There is intense dyspnoea ; the lower ribs are re- 
tracted, and the eiforts at inspiration are labored and move the upper 
part of the thorax less than the lower portion. The surface is pale 
and sometimes cyanosed. Efforts at coughing are ineffectual, but 
may bring up a frothy, clear expectoration which adheres to the 
lips. Sometimes the breathing is quite irregular and catchy, or very 
shallow ; at times the infant seems to cease breathing. 

Palpation is negative except where rales are abundant, when a 
fine rhonchal fremitus is present. There is little or no vocal fremi- 
tus ; it may be increased or it may be diminished, especially in areas 
designated vesiculo-tympanitic. 

Percussion reveals distinct small areas of dulness with a tympa- 
nitic note, slight dulness or marked dulness, especially if areas of 
collapse are present with pneumonia. Sometimes the note over the 
rest of the thorax, behind especially, is vesiculo-tympanitic. If 
the areas of collapse are small, no dulness is elicited. 

Auscultation. — In areas situated at the apex or toward the base 
of the lung the air does not seem to enter freely on inspiration, and 
the expiratory sound is hardly audible (collapse of area) or absent. 
Breathing is otherwise puerile or exaggerated, rarely bronchial. 

Very fine subcrepitant rales are heard in various parts of the 
lung. Crepitant rales are very distinctly heard in other areas, and 
are distinguished from the coarser subcrepitant rales by their fine 
quality. Areas of pneumonia can thus be recognized by the fine 
crepitations ; the atelectasis, by the absence of respiratory sounds 
and dulness. Voice sounds vary greatly. When the infant cries 
the vocal resonance may seem increased, and again normal ; or if 
the pneumonic area is extensive and is in the vicinity of a large 
bronchus, we may have tubular resonance. 

Temperature is often normal or subnormal ; later, it may be 
elevated. 

Convulsions are common in atelectasis ; in fact, they are peculiar 
to the disease. They are repeated at frequent intervals, and an 
infant may have three or four attacks of general convulsions in the 
course of the twenty-four hours. At the onset of the convulsions 
the cyanosis increases. 

Diagnosis. — The diagnosis is not possible if the area of collapse 
of the lung be small. If of considerable extent and giving rise to 
physical signs, the diagnosis may be made. 

As a rule, the congenital forms of atelectasis are more extensive 
than the acquired forms, and thus can be more readily detected, 

13 



194 THE DISEASES OF THE NEWBORN. 

The diagnosis of post-natal congenital atelectasis will depend 
upon : 

Convulsions. — Given the case of a newborn infant delivered 
without forceps or force, in the absence of signs of any other disease, 
such as hemorrhage on the surface of the brain, the presence of 
repeated convulsions, with cyanosis and dyspnoea in the intervals, 
the possibility of atelectasis should be considered. 

The presence of areas of slight dulness, or tympanitic dulness, or 
vesiculo-tympanitic resonance all over the chest. 

Fine suhcrepitant rales. 

Still finer crepitant rales. 

Areas in which the air enters incompletely. 

Prognosis. — There is no reason why an atelectatic area of the 
congenital variety should not return to the normal if the cause 
of its existence is removed and the infant regains power to in- 
flate the lung. The same may be said of the acquired form of 
atelectasis. 

Treatment. — The treatment must be directed toward stimulating 
the heart and increasing the respiratory efforts if the infant is weak 
or premature. If the heart is weak, the treatment is much the same 
as in bronchopneumonia. If the infant does not breathe satisfac- 
torily, it is well to make it cry vigorously several times in the 
twenty-four hours, so that the collapsed area of lung may be inflated 
and the mucus in the bronchi expelled. Unless made to cry, these 
infants lie torpid and hardly seem to breathe. The areas of atelec- 
tasis are thus increased. If the temperature is subnormal and the 
infant seems chilled, we may stimulate it by the application of heat 
externally, either by means of warm baths, hot- water bottles, or an 
incubator. 



VIII. SEPTIC INFECTION OF THE NEWBORN INFANT. 

Our views on the subject of septic infection of the newborn have 
undergone considerable change in the last decade. The former 
classification of certain processes, such as pysemia, septicopysemia, 
and pyogenic infection, has given way to a greater or less extent to 
broader views. 

By septic infections are meant certain general phenomena produced 
by bacterial toxins, or by the entry of bacteria into the body by 
way of the blood or lymphatic channels. The newborn infant is 
particularly susceptible to infection. At this period of life the 
ordinary means of defence are lacking, the lymph nodes and spleen 
are undeveloped, the skin is in a very vulnerable state and is a 
ready avenue of entrance for bacteria, as are also the mucous mem- 
branes. The lack of febrile reaction, also, demonstrates that in the 
newborn there is little resistance against the invasion of bacteria. 



SEPTIC INFECTION OF THE NEWBORN INFANT. 195 

Septic infectioDs may appear under the semblance of a diarrhoea, bron- 
chitis, pneumonia, hemorrhagic conditions, such as WinckePs or 
Buhl's disease, and dermatitis exfoliativa, all of which are really 
manifestations of sepsis. 

Etiology. — The most frequent causes of septic infection are the 
pyogenic bacteria, the streptococci and staphylococci. Following 
these in order of importance are the bacilli of the coli group, the 
pneumococci, bacilli of general hemorrhagic infection (Babes), the 
bacillus pyocyaneus (Neumann), the capsule bacillus of Dungern, the 
bacillus enteritidis (Gartner), found in hemorrhagic affections resem- 
bling WinckeFs disease, and the bacillus of Finkelstein, found also 
in hemorrhagic conditions. The bacteria exist in the air of hospital 
wards (Emmerich, Babes, Gartner, Prudden). They are found in 
the normal breast milk (Neumann), and in the milk of breasts which 
are the seat of ulceration, fissure, or abscess. The body of the 
mother, the lochia, and also the liquor amnii after rupture of the 
membranes, are all sources whence bacteria may gain access to the 
body of the newborn infant. As a rare source of infection may be 
mentioned the incubator in which septic cases have been nursed 
(Allard). The bath-water has been the means of causing epidemics 
of dermatitis exfoliativa and WinckePs disease among infants in 
institutions. 

Hetero-infection may also be mentioned, such as obtains at the 
hands of the accoucheur, from unclean instruments and dressings. 
Among the autoinfections may be mentioned the conditions which 
obtain in the skin of the infant, which is in process of desquamation. 
Deprived of its horny layer, which is absent in the newborn, bacteria 
can penetrate the sudoriparous and sebaceous follicles. Thus, any 
pustule may give rise to a general or local process. 

Umbilical Site. — The umbilical site is not considered as frequent 
an avenue of infection as in former days when puerperal disease was 
more common. To-day we have occasional epidemics of umbilical 
as well as other forms of infection ; but with modern methods this 
form of infection has become more and more infrequent. 

Bacteria or their toxins may thus gain access to the body through 
the intact or wounded skin, the umbilicus, the mucous membranes 
(buccal or pharyngeal), through the lungs in the respired air, through 
the digestive tract by means of the food, through the conjunctivae 
and the ears, and finally through the genital tract. 

Respiratory autoinfections occur through the aspiration of liquor 
amnii or vaginal secretions. Bacteria may gain access through a 
minute loss of the lining epithelium of the respiratory tract. 

Digestive Infections. — These must be regarded as rare. The 
manner in which the bacteria gain access to the circulation from the 
gut has been demonstrated by Booker and Escherich. They have 
shown that streptococci may gain access to the general circulation by 



196 THE DISEASES OF THE NEWBORN. 

way of lesions of the mucous membrane of the gut. Conjunctival 
infection, except in specific cases, is rare. 

Otogenic Infection. — The ears may be the seat of septic infection, 
for pus has been found in the ear of the newborn, and thence has 
entered the general circulation through infection of the lateral sinus, 
causing sinus thrombosis, meningitis, and encephalitis. 

Urogenital Infection. — This may occur by way of the urogenital 
tract. As first pointed out by Epstein, an inflammation of the vagina, 
bladder, or kidneys may be a starting-point of general infection. 

Among the predisposing causes of infection of the newborn must 
be considered congenital weakness. Thus, the greatest number of 
cases occur among the weakly infants of syphilitic or tuberculous 
parentage, premature infants, and those possessing birth anomalies. 

Symptoms. — It is impossible to particularize any form of 
sepsis so far as the general symptoms are concerned. The reac- 
tion in the newborn infant is so imperfect and the signs are so 
equivocal that it is often only at the autopsy table that the nature 
of the lesion is determined. It will be convenient, therefore, simply 
to enumerate the objective changes noted in the various structures 
of the body in this disease. 

The skin may be dry, or the seat of localized oedema or sclerema. 
It may be "the seat of erythema of a polymorphous variety, either 
on the body or on the extensor surface of the arms or hands. There 
is sometimes a general or localized cyanosis. A peculiar form of 
this cyanosis has been described by Finkelstein — the so-called angio- 
spastic cyanosis — in which a central pallor and peripheral lividity 
are present in the patches. The cyanosis may be limited to the 
hands and feet. 

Eruptions of a pemphigoid character are sometimes seen in cases 
of sepsis of the newborn infant. The vesicles may be the seat of 
suppuration, or there may be ulcers and intertrigo varying from 
superficial erosions to extensive areas of gangrene. The skin may 
be pale or icteric in hue. There may be erysipelatous patches, furun- 
cles, and abscesses of a multiple variety. 

The mucous membrane of the mouth is dry and fissured, and the 
tongue dry and coated. The roof of the mouth may be the seat of 
ulcerations superficial or deep, occurring at the median raphe, where 
we find normally Epstein's pearls, or laterally over the hamular 
processes of the palate bone (Bednar's aphthae). The mouth may 
be the seat of pseudomembranous deposit not due to the diphtheria 
bacillus (Epstein). In these cases of sepsis sprue may engraft itself 
on the mucous membrane of the mouth and extend to the pharynx, 
oesophagus, and stomach. The vagina in female infants may be the 
seat of catarrhal or pseudomembranous inflammation. 

Umbilicus. — Normally, pathogenic bacteria are found about the 
stump of the desiccating cord, but do no harm ; under favorable con- 



PLATE V. 



\ 



c/. 



Sepsis in the Newborn Infant. Suppuration of the 
right knee-joint. Osteomyelitis of the epiphyses of the 
bones forming the joint. 



SEPTIC INFECTION OF THE NEWBORN INFANT, 197 

ditions of sepsis, however, these bacteria may increase in numbers 
and virulence and become a source of great danger. In septic 
conditions the cord does not fall off promptly. The tissues about 
the umbilicus are inflamed and the seat of phlegmon and suppura- 
tion. Pus may burrow downward toward the bladder along the 
course of the foetal structures. The bloodvessels of the cord may be 
the seat of inflammation, as will be shown later. In some forms of 
sepsis in which the infectious material may have gained entrance 
through the umbilicus, the latter may show absolutely no change 
from the normal. 

Bones and Joints. — There may be swelling in the muscles about 
the joints, as in forms of intramuscular abscess, or the joint itself 
may be the seat of septic suppuration or so-called osteomyelitis 
(Plate v.). The shaft of the bone or the epiphysis only may be 
involved. One or many joints may be the seat of suppuration. 

Nervous System. — Functional symptoms, such as apathy, restless- 
ness, or convulsions, may be present, or there may be localized facial 
paralysis or paralysis of the extremities, traceable to meningitis or 
encephalitis. Hemorrhages in forms of sepsis may give rise to 
paresis simulating the traumatic palsies of the newborn. 

Respiratory Tract. — The respiratory tract may present catarrhal 
or pseudomembranous inflammation of the nose, tonsils, larynx, or 
trachea. The bronchitis and pneumonia, especially in the septic 
forms of diarrhoea, may be of obscure nature and run an insidious 
course. 

The bronchopneumonia which accompanies sepsis of the newborn 
is toxic in its nature, with but little febrile reaction and dyspnoea. 
Pleurisy and abscess of the lung may occur, but are frequently only 
discovered at the autopsy table. 

Circulatory System. — The heart may be the seat of septic endo- 
pericarditis. This form of pericarditis is rarely diagnosed. 

Stomach and Intestines. — The intestinal tract may be the seat of a 
septic diarrhoea. There may be vomiting with severe gastro-intesti- 
nal symptoms, not infrequently with blood in the vomited matter as 
a manifestation of toxaemia. In the cases of septic diarrhoea de- 
scribed by Fischl and Czerny there was complicating bronchopneu- 
monia of a severe type. 

Liver. — The liver may be the seat of enlargement in cases of ex- 
tended duration, but the spleen is rarely so. 

Urine. — The urine may contain albumin and blood, not infre- 
quently leucocytes and casts, indicating a septic nephritis. 

Body- weight. — The body-weight diminishes markedly and rapidly. 

Temperature. — The temperature is not characteristic. In the 
severest forms of sepsis it may be normal or subnormal ; in other 
cases there may be a rise of a degree or more. I have seen this in 
milder cases. A new complication may be ushered in with a rise 



198 THE DISEASES OF THE NEWBORN. 

of temperature, as often happens with older infants and children, 
but this is not necessarily so. 

Hemorrhages in the Eye. — In some cases examination of the 
fundus oculi shows the presence of hemorrhages. 

Morbid Anatomy. — The changes in the skin have been described. 
Those of the umbilicus will be found under the section of Umbilical 
Infection. The appearances in the mouth, nose, and throat have 
been described, as well as those of the lungs. The alterations in the 
gastroenteric tract are detailed in the chapter on Diseases of the 
Gastroenteric Tract. 

The liver and kidneys are the seat of parenchymatous or diffuse 
suppurative changes. The peritoneum is ordinarily intact, although 
formerly authors believed it to be frequently involved. The peri- 
cardium, endocardium, and myocardium may be the seat of slight 
or marked changes. Microscopical examination of the blood may 
reveal the infecting bacteria. 

Diagnosis. — The origin of some cases of sepsis of the newborn 
infant is so obscure that not only is a diagnosis made with difficulty, 
but it is not always j)ossible to determine the point of entrance of 
the infectious agent. In cryptogenetic cases no lesion may be visi- 
ble. If an infant cries when it is diapered or washed in the bath, 
the joints should be examined for suppuration. A pseudomem- 
branous deposit or an ulceration in the mouth is a sign of traumatism 
with infection. A diarrhoea in the newborn infant is of serious 
moment. The umbilicus, if swollen or red, should receive due con- 
sideration. Lumbar puncture has been proposed for the examina- 
tion of the cerebrospinal fluid for micro-organisms, but this is hardly 
justifiable unless a meningitis be present. It has been suggested 
that the blood should be examined for micro-organisms by means 
of culture. In several of my cases in which this was attempted it 
was impossible to obtain the requisite amount of blood sufficient for 
a culture, the vessels being quite small at this age, and it being 
hardly justifiable to enter an artery or a very large vein in order to 
obtain the requisite amount of blood. 

Puncture of the spleen for the detection of micro-organisms has 
been advised. Such a procedure may or may not be advisable, 
according to the indications in the case. 

Course and Prognosis. — Some forms of acute sepsis prove fatal 
in a few hours. Others, and they are the most common, last from 
a few days to a week. Others give no symptoms and result in sudden 
death of the infant. Finally, the subacute cases, which are com- 
plicated with progressive emaciation, diarrhoea, and pneumonia, 
extend over two or more weeks. Septic osteomyelitis and chronic 
omphalitis are especially protracted. The prognosis in these cases 
is always grave. Mild forms of intestinal sepsis, after pursuing a 
short course with fluctuating temperature, may recover completely. 



OMPHALITIS. 199 

In subacute cases the danger of complications is ever present. 
Even if bacteria are found to be present in the blood, a recovery is 
not always impossible. 

Treatment. — There is no specific treatmeut for sepsis in the new- 
born infant. Prophylaxis is of the utmost importance. The hands 
of the accoucheur must be as clean in handling the newborn infant as 
in the treatment of the mother. The cord is tied v/ith precautions 
described elsewhere. The mouth is not washed. As Epstein has 
pointed out, Bednar's aphthae and pseudomembranous inflammations 
are thus avoided. The nasal passages are not inspected more than 
is absolutely necessary. The bath-water should be clean and not 
below 38° C. (100° F.). The food should receive attention. The 
infant should not nurse a fissured or an inflamed breast. The breast 
nipple should be cleansed before and after nursing, as stated in the 
section on Hygiene. The room in which the child sleeps should be 
ventilated. Contact with the secretions of the mother (lochia) should 
be avoided. 

Therapeutic measures will be directed toward the indication in 
each case. If a pneumonia or gastroenteritis be present, this com- 
plication is treated on the same lines as a primary infection of a simi- 
lar nature. Osteomyelitis resulting in an accumulation of pus in 
the joints will receive surgical treatment. Cases complicated by 
meningitis also will receive the treatment indicated under the sec- 
tion on Meningitis as a Primary Infection. If the indications 
exist, such as pressure eflPects, a lumbar puncture may be performed. 
Abscesses are opened and erysipelatous and purulent skin lesions 
treated according to surgical procedure in each case. 

The strength should be supported, and for this purpose alcohol 
may be used with small doses of strychnine. The antistreptococcic 
sera are of doubtful efficacy. The administration of alkalies, such as 
the salicylate, benzoate, and carbonate of sodium, has been strongly 
advocated. High saline enemata are advised by Sahli. Subcuta- 
neous and intravenous saline injections have not proved successful. 

IX. DISEASES OF THE UMBILICUS. 

Diseases of the umbilicus are classified as those which are purely 
local, such as blenorrhoea, phlegmon, gangrene, and erysipelas ; those 
which begin as a local lesion and result in a general infection, such 
as arteritis and phlebitis umbilicalis, hemorrhage from the umbilicus ; 
and, finally, those which may be classified as anatomical deficiencies, 
the hernise umbilicales. 

Omphalitis. 

The umbilical cord dries up and drops off in five days, leaving a 
granulating stump. In the case of weakly infants the cord may not 



200 THE DISEASES OF THE I^EJVBOR]^. 

fall off until much later. The stump may become inflamed and pus 
may form. This, in the majority of cases, is due to infection. 

Infection of the site of the ligature of the umbilical cord may 
easily occur in the newborn, first, because bacteria are normally 
present, or may be conveyed to the site not only at the time 
of ligation of the cord, but after the stump has separated and 
the cord healed. Infection usually takes place at the time of 
ligation or before the cord separates from the stump. The appear- 
ance of the stump in omphalitis varies. In some cases the inflam- 
mation is slight, but in others the tissues are red, infiltrated, and 
coated with necrotic masses resembling pseudomembrane. Numer- 
ous small abscesses may be present. The great danger is that the 
process may involve the umbilical vessels. If the inflammation 
remains local, recovery is the rule. If the vessels become involved, 
sepsis may result. 

Treatment. — Proper ligation and care in dressing the cord 
will in most cases prevent subsequent infection. Cleanliness is of 
the first importance. The hands, instruments, and the tape used for 
ligation should be scrupulously clean. The care of the stump of the 
umbilical cord has been a matter of much discussion. The ideal 
method of dressing the stump has not as yet been found. Some 
prefer not to bathe the child until after the stump has separated, in 
order to facilitate the mummification of the cord ; others have in- 
sisted, if the dressing, hands, and water are clean, that no danger 
results from the bath, and that a daily dressing of the cord is not 
improper. This will be taken up elsewhere. If the cord is dressed 
daily, it should be dusted with some bland powder, such as dermatol, 
orthoform, or xeroform, even after the stump has separated and until 
the wound is completely healed, for the site of the umbilical cord is 
susceptible of infection even after the healing has taken place. The 
best dressing for the cord is sterilized absorbent gauze several layers 
thick, and perforated in the centre. The cord is passed through 
this perforation and enclosed in the gauze. This dressing is re- 
newed daily. If a suppurating surface appears, it should be treated 
on general surgical principles. As a rule, ointments should be 
avoided. The ordinary sterilized wet-dressing is sufficient. 

Umbilical Fungus. 

{Granuloma.) 

In some cases the stump does not heal after the cord has sepa- 
rated, and a granulating surface which presents a fungoid appearance 
remains. The granulating mass may become as large as a bean and 
be pedunculated. There is secretion of pus. The affection is a 
benign one, and should not be confounded with the so-called entera- 
tomata^ which are rare. The latter are composed of smooth muscu- 



tJLCER OF THE UMBILICUS. 201 

lar fibre and tubular glands. These umbilical tumors have been 
described by Kolaczek, who believes that they are formed by the 
prolapsus of a persistent omphalomesenteric duct. Yon Heukelom 
asserts that they are intestinal protrusions through true diverticula 
of Meckel. Adenoid tumors of the umbilicus have been described 
by Lannelongue and Fremont. Hiittenbrenner has reported a poly- 
poid tumor of the umbilicus, which he believed to be the remains of 
the allantois. 

Treatment. — If small and flat, the granulations are touched 
daily with silver nitrate stick and a dry dressing is applied ; or 
the granulations may be carefully scraped off and the stump dressed 
with sterilized gauze after bleeding has ceased. If the growth is 
large and pedunculated, it should be ligated at its base with silk or 
catgut and a sterile gauze dressing applied. In a day or two the 
mass separates and healing takes place. 

Blennorrhoea of the Umbilicus. 

Blennorrhoea of the umbilicus is a condition in which there is 
considerable suppuration and secretion of pus after the stump of the 
umbilical cord has separated. The area of skin around the umbili- 
cus is red and excoriated. Under proper treatment this condition 
is curable. 

Phlegmon of the Umbilicus. 

This is an inflammatory reaction of the umbilical wound due to 
some local infection. There is an omphalitis umbilicalis. The 
region of the umbilical wound is red, inflamed, and infiltrated, as is 
also the neighboring skin. There is pain. The condition may ret- 
rograde or the skin may break down and ulcerate, or abscesses may 
cause infection of the peritoneum. In the latter case the disease is 
invariably fatal. 

Ulcer of the Umbilicus. 

The umbilical wound is here replaced by an ulcer of an irregular 
shape ; the neighboring skin is red and swollen, and there is a dis- 
charge of discolored pus. There is pain, uneasiness, and fever, or 
there may be no temperature. In some cases ulcers may exist with 
a pseudomembranous deposit. The disease, however, has nothing 
in common with true diphtheria, but is due to wound infection of a 
streptococcic nature. The umbilical wound may become infected 
with diphtheria. In such a case the diphtheria bacilli will be found 
in the discharges and in the membrane of the wound. 



202 THE DISEASES OF THE NEWBORN. 

Gangrene of the Umbilicus. 

This is a very serious condition, and occurs in weak infants 
amid unhygienic surroundings. The disease may develop in from six 
to thirty days after birth ; the wound becomes bluish or greenish 
red, discolored, or is converted into a discolored, greenish, bloody 
mass secreting ichorous pus. The gangrenous process may involve 
the skin, and usually spreads into the depths of the abdominal wall, 
involving the urachus, the umbilical vessels, and finally the perito- 
neum. The prostration is great, and there may be little or no 
temperature ; or the temperature may even be subnormal. Under 
these conditions there results a general sepsis, and the infant dies of 
toxaemia or complicating peritonitis. In some cases the gangrenous 
process begins in the subcutaneous tissues, spreads thence to the 
peritoneum, the overlying skin remaining tolerably intact. This 
latter form of necrosis is only discovered and verified postmortem. 

Treatment. — The treatment of blennorrhoea of the umbilicus 
consists in applying some dry dressing with a dusting powder, such 
as dermatol. By applying this powder daily the condition is gener- 
ally controlled. 

Phlegmon of the umbilicus is treated in the same manner as an 
ordinary phlegmon, by means of any convenient wet dressing. 
Liquor Burrowii or Thiersch's solution forms a very convenient 
dressing. 

Ulcer of the umbilicus is treated by means of wet dressing, or 
by the application of one part of balsam of Peru to four parts of 
castor oil, applied on gauze. The balsam-and-oil dressing is cer- 
tainly very agreeable, and successful in many cases. 

Gangrene of the umbilicus is treated on surgical principles in the 
same manner as gangrene in other parts of the body. 

Erysipelas of the Umbilicus. 

This affection may involve the umbilicus and spread thence to 
the surrounding skin. It may, however, remain local ; but, as a 
rule, it spreads, involves most of the surface of the abdomen, and 
in many cases ends in gangrene. If erysipelas remains localized, 
recovery may result ; if it spreads, however, it is generally fatal. 

Infection of the Umbilical Vessels. 

{Arteritis Umbilicalis. ) 

This is an infection which may take place before or after the 
separation of the umbilical stump, and may occur by way of the 
bloodvessels or the perivascular connective tissue of the cord. 

In this affection the perivascular connective tissue of the cord 
may first become infiltrated with serum and be oedematous ; later, the 



INFECTION OF THE UMBILICAL VESSELS. 203 

various coats of the arteries are affected. Thrombosis results, with 
disintegration of the thrombi. The lymph- vessels in the connective 
tissue of the cord carry the infectious material to the various parts 
of the body. 

It must not be forgotten that the normal stump of the cord 
contains bacteria ; to be sure, of the non-virulent type or of reduced 
virulence. These cause no trouble. Given, however, uncleanliness, 
either in the dressings or otherwise, these bacteria combined with 
others may give rise to serious infection. The lochia, though not fre- 
quently, may be a source of infection. This infrequency is due to 
our means of asepsis, and to the protection which our present 
methods afford against epidemics of umbilical infection. 

Umbilical arteritis is a wound infection. It is most frequently 
seen in institutions, and is the result of implantation of septic matter 
on the umbilical wound by the hands or instruments, or through the 
bath-water or unclean dressings. Cases have occurred coincident 
with the presence of blennorrhoea. 

Morbid Anatomy. — There may be simple ulceration with dis- 
coloration of the umbilicus and purulent material in the lumen of 
the artery, with infiltration of perivascular tissue. The vessels 
running from the umbilicus appear as thickened discolored cords. 
The perivascular tissue is infiltrated. The process may begin about 
a centimetre behind the umbilicus and extend downward toward the 
bladder. The umbilical stump may be normal in appearance or 
inflamed. The lumen of the arteries contain thrombi. The vessels 
may be dilated and contain disintegrated purulent masses. There 
may be lobar or lobular pneumonia, with pleurisy and hemorrhagic 
infarction of the lung. Parenchymatous inflammation of the liver, 
kidney, and spleen, and suppuration of one or several joints (see 
Osteomyelitis) may be observed. Peritonitis may be a complica- 
tion. 

The bacteria found in most of these cases have been streptococci 
or staphylococci. 

There may be metastatic abscesses in the various organs ; the 
tissue of the heart may be the seat of parenchymatous degeneration ; 
the epi- and pericardium may be the seats of ecchymoses and hemor- 
rhages, as also the pleura. There may be suppuration in the cavity 
of the pleura. 

Organs apparently normal in gross appearance may be the seat of 
parenchymatous degeneration. 

Symptoms. — The symptoms of arteritis umbilicalis are often 
indefinite and give no clue to the cause of the illness. The infants 
gradually emaciate and succumb, the fatal issue supervening quite 
suddenly. The umbilicus may in these cases have been long healed 
and show no evidence of disease ; in other cases it is inflamed. 
There is a sinus leading downward and backward toward the bladder, 



^04 i:he diseases of the nbwbouk 

and from this pus exudes. A tense cord-like structure, the inflamed 
umbilical vessels, is felt beneath the abdominal wall. Sometimes 
the first intimation of serious disease is seen in the joints. The 
mother may tell the physician that the infant cries when it is 
bathed or dressed. In these cases the knee, ankle, or hip may be 
swollen, tense, and the seat of exudate. A septic osteomyelitis of 
the epiphyses of the joint is present, resulting in a suppurative 
arthritis. As a rule, more than one joint is involved. In other 
cases the symptoms are indefinite : there is a slight febrile move- 
ment. The skin has a slightly gray or icteric hue and may be the 
seat of erythema or hemorrhages, as mentioned under the heading 
of Sepsis. There may be a violent gastroenteritis or rapidly fatal 
pneumonia, or the lung symptoms may be equivocal and not very 
marked. In other words, there is a sepsis with the symptom- 
complex of a pneumonia or gastroenteric disturbance. 

Hennig's symptom, which consists of a so-called depressed triangle 
reaching from the umbilicus to the pubis, bounded by red lines indi- 
cating the inflamed arteries, accompanied by oedema of the wall of 
the abdomen, is not always present or to be depended upon. 

Course. — The cases may be classed as acute, resembling sepsis 
and running a very rapidly fatal course, simulating a diarrhoea or 
pneumonia. Other cases may recover ; these are the mild infections. 
The uncommon cases are those which run a chronic or subacute 
course with metastatic abscesses throughout the body. 

Prognosis. — These cases are generally fatal. A few of the mild 
cases recover. In these, however, it is a question as to whether the 
vessels have been involved or whether there was a true infection of 
a septic nature. The prognosis is especially unfavorable in prema- 
ture infants. 



Phlebitis Umbilicalis. 

In this affection the veins which pass from the umbilicus to the 
liver are the seat of an inflammatory process similar to that aifecting 
the arteries in the affection just described. There is a true phlebitis, 
with pus in the lumen of the veins, in some cases extending into the 
liver. The brandies of the portal vein are involved. The picture 
presented is that of metastatic abscesses, as contradistinguished from 
the parenchymatous degenerations which make up the picture of 
arteritis umbilicalis. The umbilical vein is dilated and filled with 
pus ; the intima is swollen, inflamed, or eroded ; the suppuration 
extends to the liver, which, with the spleen and kidneys, may be the 
seat of metastatic abscesses. There is peritonitis of the diffuse 
variety. Pleuritis, meningitis, and 'brain abscess may result. There 
may be abscesses in the skin and also in the joints, the whole picture 
being that of pyaemia. In some cases the symptoms resemble those 



HEMORRHAGE FROM THE UMBILICUS. 205 

of peritonitis complicated with icterus ; the respirations are shallow, 
the abdomen tense, and the thighs are flexed on the abdomen. 

Treatment. — It is hardly necessary to say that prophylaxis is in 
all septic aifections the mainstay of the physician. Once inaugurated, 
infective processes in newborn infants are progressive. In cases of 
the umbilical type I have advised laying open the structures passing 
from the umbilicus to the bladder, curetting the sinus thus formed, 
and inducing healing from the bottom. Recovery has followed in a 
few exceptional cases. The operation should be performed before 
general infection has occurred. Van Arsdale operated on one of 
these cases for me and obtained an apparent recovery — that is to 
say, the sinus leading from the umbilicus healed and there were no 
symptoms for weeks after the operation. 

In some recorded cases the liver has been incised for abscesses. 
One case occurred in an infant three months of age, the subject of 
umbilical phlebitis. The results obtained with antistreptococcic sera 
have not been encouraging. 

Hemorrhage from the Umbilicus. 

( Omphalorrhagia. ) 

Hemorrhage from the umbilicus may occur (a) from the vessels of 
the umbilical cord or (6) from the umbilical wound itself (parenchy- 
matous). 

Hemorrhage from the vessels of the cord may occur if the liga- 
ture has not been properly applied ; but faulty ligation alone will 
not account for the hemorrhage in all cases. Runge states that if 
the cord is cut ten or fifteen minutes after a healthy infant has cried 
lustily there will be little hemorrhage — certainly not one threaten- 
ing life. The diminution of arterial pressure in the bloodvessels at 
this point, due to the establishment of the pulmonic circulation and 
the natural contractility of the vessels, prevents hemorrhage. The fact 
that infants among savage peoples and the young of lower animals do 
not bleed to death, although the cord is not ligated, but simply 
divided, is thus explained. If an infant, therefore, bleeds after liga- 
tion of the cord, the reason must be sought in some physiological or 
anatomical defect of the bloodvessels. We possess no data which 
would explain the absence of normal arterial contraction in the ves- 
sels of the cord. Inasmuch as this condition may be present during 
the first days after birth, great care should be taken that the ligature 
is properly applied. Caution should especially be exercised with pre- 
mature infants, in whom the bloodvessels are in an embryonal state. 

After the separation of the umbilical stump a few drops of blood 
may be seen on the wound from time to time. This is of no moment. 
The wound should be dressed with a salicylic powder and amylum 
(1 : 5), and covered with a dry dressing. 



206 THE DISEASES OF THE NEWBORN. 

Idiopathic Hemorrhage from the Umbilicus. 

{True Omphalorrhagia.) 

Occurrence. — Winckel, quoted by Eunge, has seen only 1 case 
in 5000 births of true idiopathic hemorrhage from the umbilicus. 
Males are more frequently attacked than females. I have seen a 
few cases of this affection. 

Etiology. — According to Grandidier, infants apparently healthy 
and strong are for the most part affected. This form of hemorrhage 
occurs also in infants suffering from congenital syphilis, septic infec- 
tions, or the acute fatty degeneration of the newborn. In some forms 
of congenital syphilis there may be hemorrhages into the skin, stomach, 
intestine, and internal organs. In these cases it is not surprising 
that hemorrhage should also occur from the umbilicus. Icterus, 
due to syphilitic affections of the liver and lung, may be present. 

In 51 cases of hemorrhage from the umbilicus, Epstein found 
pronounced septicaemia in 24. The affection is especially prevalent 
under unhygienic conditions and in foundling asylums. Klebs, 
Eppinger, Cohnheim, and Weigert have described cases of hemor- 
rhage in which micro-organisms of various kinds Avere found in the 
blood and in the hemorrhagic areas. Bacterial colonies were found 
in the arterial thrombi and in the lungs and kidneys. 

The occurrence of hemorrhage from the umbilicus in BuhPs dis- 
ease is elsewhere described. 

Symptoms. — About the fifth day after birth, immediately follow- 
ing separation of the umbilical stump, blood is seen to ooze from 
the umbilicus. It does not appear to issue from any particular 
vessel, but oozes from the whole umbilical wound, as from a sponge. 
The flow may be slight at first and then profuse, or may be profuse 
from the outset. Pressure upon the wound may cause the hemor- 
rhage to cease, but the flow begins when pressure is withdrawn. 
In some cases the infants have enjoyed excellent health previous to 
the hemorrhage. In others there may have been a slight icterus or 
diarrhoea. However this may be, after bleeding commences cya- 
nosis and icterus of the general surface appear, giving the skin 
a peculiar bronzed appearance. There are hemorrhages from the 
stomach and gut. Ecchymoses appear in the vicinity of the umbili- 
cus and on other parts of the trunk. (Edema of the ankle-joints 
and wrists supervenes. The hemorrhage from the umbilicus is the 
most characteristic symptom, and cannot be controlled by any 
means. The blood coagulates very slowly. 

Duration. — The disease lasts from a few hours to two weeks. 
Grandidier's statistics give a mortality of 83 per cent. Death 
ensues in collapse, with convulsions. 

Treatment is directed to controlling the hemorrhage by pressure 
or by transfixing the umbilical wound. From a study of the path- 



UMBILICAL HERNIjE. 207 

ogeny of this affection, it is evident that no form of local treatment 
can be successful. 

Umbilical Herniae. 

In newly born infants we distinguish two varieties of hernia at 
the umbilicus. 

The first form is of serious character. It is really a hernia of 
the umbilical cord (hernia funiculi umbilicalis). The condition is 
due to an arrest of development, as a result of which there is a true 
defect in the abdominal wall at the situation of the umbilicus. The 
gut prolapses and is covered by the amnion of the cord and Wharton's 
jelly, beneath which is the peritoneum. The latter is immediately 
over the gut. Many of the infants thus affected are premature. 
In others deformities are present. The hernia is a round or oval 
tumor of the size of a walnut or an orange, located in the region 
of the umbilicus, and is continuous w^ith the cord. The sac of the 
hernia is formed by the peritoneum and amnion. The abdominal 
walls form the border of the sac. Gut, liver, spleen, kidney, or 
pancreas may be found in the sac. 

If treatment is not instituted at the time of separation of the 
cord, and the hernia is large, ulceration, gangrene, or septic perito- 
nitis in the sac contents may result. 

The second and most common form of hernia in this region 
is due to a weakness at the point of insertion of the cord. The 
hernia becomes apparent a few weeks after birth, when the cord has 
completely cicatrized. It is then noticed that when the infant cries 
there is a protrusion at this point. The protrusion may be small or 
large, and is covered by the thin cicatrized skin. The hernia may 
be central or at one side, or a little above or below the centre of the 
umbilical ring. 

The treatment of the first form is purely surgical, and consists 
in splitting open the sac and sew^ing the abdominal parietes in 
apposition. The treatment of the second form is simple. As a 
prophylactic measure a small pad should be placed on the abdomen, 
underneath the binder, and should be worn for some time after 
the stump is healed, in order that there may be no protrusion of the 
wall and gut during crying spells. If the hernia has taken place, 
a firm pad, made by enclosing a piece of thick cardboard, one 
and a half inches in diameter, in a piece of linen, should be 
applied, and supported by rubber plaster. Another method is to 
reduce the hernia, fold it inward by means of the apposing abdominal 
walls, and secure the walls thus brought together with plaster. The 
plaster should be renewed every three days lest ulceration of the 
skin result. As soon as the muscles of the abdomen gain strength 
and the infant is able to stand, the opening at the umbilicus closes 
and the hernia remains reduced. 



208 THE DISEASES OF THE NEWBORN. 

X. PERITONITIS OF THE NEWBORN. 

Occurrence. — This affection may occur from the first to the 
seventh day after birth, and sets in, as a rule, with vomiting, pain, 
as evidenced by crying ; diarrhoea, tympanitis, disappearance of the 
liver dulness, dulness in flanks, showing the presence of fluid in the 
abdominal cavity. Peritoneal fluid may collect in the pelvis and 
appear in the scrotum, simulating hydrocele. In such a case the 
right side of the scrotum is mostly affected, and there is accompany- 
ing oedema. The temperature may be as high as 40° C. (104° F.). 
There are restlessness, emaciation, facies, and death supervenes in 
from four to five days. Infection is not always limited to the peri- 
toneum : there may be blennorrhoea, phlegmon, erysipelas, hemor- 
rhages, or gangrene of the umbilicus, and with these we may have 
arteritis, pleurisy, and visceral abscesses. Peritonitis of the new- 
born may originate at the umbilicus, which is a port of entry for 
bacteria. 

The prognosis of these cases is grave ; most of them result 
fatally. 

XI. TETANUS OF THE NEWBORN INFANT. 

( Trismus Neonatorum. ) 

Tetanus of the newborn is an acute infectious disease or intoxi- 
cation, strictly speaking, characterized by trismus and tonic mus- 
cular spasms, rarely convulsions. 

Tetanus of the newborn infant is in the majority of cases due 
to infection of the umbilical wound by the tetanus bacillus. The 
bacillus, is conveyed to the wound by means of unclean hands, 
bandages, or filth of any kind. As a result of the growth of the 
bacillus ptomaines are formed, enter the circulation, and are widely 
distributed throughout the body. Infection may occur at the time 
of the ligation of the cord or during the separation of the stump. 
In 8 per cent, of the cases the disease manifests itself immediately 
after birth (Hartigan). 

Hartigan's assertion that in most cases symptoms appear from 
the first to the fifth day after the separation of the stump of the 
cord is incorrect. As a rule, the onset is from the fifth to the 
twelfth day after birth (Runge). It is rare after the third week. 
The incubation period in the human subject varies from one to 
sixty days. In animals which have been the subject of experiment 
the period of incubation has been but a few hours. Subdural injec- 
tions in animals have given the shortest incubation period. 

Tetanus is common in districts in which uncleanliness in the 
methods of treating the umbilical cord prevails. It is endemic in 
the Faroe islands, and is common in the Hebrides, Cuba, and 



TETANUS OF THE NEWBORN INFANT. 209 

Jamaica. Negroes, especially, are prone to the malady, on account 
of their lack of cleanliness in treating the cord. Tetanus of the 
newborn infant has been demonstrated by Beumer and Peiper to be 
identical with tetanus in the adult. 

Morbid Anatomy. — Beck has described two cases of tetanus 
with swelling of the motor ganglion-cells, and degeneration of the 
peripheral portion of the cells with atrophy. There are also changes 
in the chromatin of the cell. Congestion and hemorrhages in the 
brain and cord, serous exudates in the cord, and congestion of the 
internal organs, due to convulsions, are present. 

Symptoms. — There is a premonitory period of restlessness. The 
infants awake abruptly from sleep. They nurse badly, let go of the 
nipple suddenly, and cry. The peculiarity of the disease in infants 
is the predominance of trismus, with which the attack begins. The 
lower jaw becomes rigid and fixed at a distance of a few lines from 
the upper jaw. It is impossible to introduce the nipple between 
the teeth. At first there is a tremulous contraction of the muscles 
of the lower jaw. It is then noticed that the infant is unable to 
open the jaw, and on slight irritation, either with the fingers or with 
the breast nipples during nursing, the lips become puckered into the 
position of playing the flute, and the jaw is contracted and fixed. 

The muscles of deglutition become affected, so that swallowing is 
impossible, and all fluid introduced is returned or rejected. The 
forehead is wrinkled, and the palpebral fissure diminished. The 
condition of rigid spasm spreads to the other muscles of the body, 
such as those of the neck, back, and extremities, and there is opis- 
thotonos. At intervals this spasm relaxes. At the outset, during 
the intervals between the attacks of rigidity, the body is lax ; dur- 
ing such intervals the unfortunates may obtain some rest and take 
nourishment. These intervals become shorter and shorter, until 
finally the body is in a state of constant rigidity, resting on the 
heels and the back of the head. The muscular spasm is a tonic 
one, called forth by the least irritation, or by sound or a moving 
body in the room, or even by a draft of air. Dyspnoea with result- 
ant cyanosis is present when the muscles of respiration become 
affected. Deglutition is impossible. There is no cry, on account 
of spasm of the laryngeal muscles. The temperature may reach 
41° C. (106° F.). In protracted cases it may be normal. The 
pulse is accelerated. The urine and faeces are passed involuntarily. 
There is albumin in the urine. The respirations are superficial. 
The heart action is increased ; the pulse may be 200. During a 
contracture the skin is dark red and cyanotic. Icterus may be 
present. The face is fixed in expression and cedematous. 

Duration. — The disease lasts from a few days to three weeks. 
Death may ensue in from one to six days from asphyxia or exhaus- 
tion. In rare cases the attacks become less and less frequent, and 

14 



210 THE DISEASES OF THE NEWBORN. 

finally cease. Fracture of the bones and rupture of the muscles are 
among the complications. 

Diagnosis. — The diagnosis offers no difficulties. The sudden 
onset and rigid contraction of the muscles of mastication and deglu- 
tition, the intensification of the contractures by the least irritation, 
the opisthotonos with intervals of relaxation and contraction, the 
temperature — all tend to aid in the diagnosis. The only question 
which can arise is that relative to the differentiation of tetanus from 
contractures with paralysis due to traumatism after birth. In the 
latter case, however, there will be corresponding pareses, such as are 
seen in the face. 

Again, tetanus may be confounded with cerebrospinal menin- 
gitis in the newborn, due to infection with staphylococci, strepto- 
cocci, or meningococci. In meningitis there is no trismus or tetanic 
spasms, though there may be rigidity of the muscles of the neck 
and back. In doubtful cases lumbar puncture will reveal micro- 
organisms of meningitis in the cerebrospinal fluid. 

Prognosis. — The prognosis is grave. Baginsky lost all of his 
cases in newborn infants, while Escherich, Soltman, and Monti 
report recoveries. Cases which occur late, after separation of the 
cord, give a better prognosis (Papiewski). Patients die of exhaus- 
tion, as a result of sleeplessness, lack of food, and general strain on 
the nervous system. 

Treatment. — Prophylaxis is of the utmost importance in this as 
in other diseases of the newborn infant. Cleanliness in handling the 
cord is of the first importance. Escherich cauterizes the stump of 
the cord, to destroy any bacilli of tetanus which may be present. 
On the appearance of trismus, the treatment is first directed to the 
relief of the tonic spasms. Chlorate hydrate in 1-grain (0.06) doses 
every few hours, by mouth, or by the rectum, is a very useful 
drug. Calabar bean in the form of the extract is recommended 
by Monti, who gives y^-g- grain (0.0005) subcutaneously, repeated 
until the desired effect is obtained. Cannabis indica, J grain (0.03) 
every two hours, is also given internally. Curare has been used 
but little with the newborn infant. Of the other remedies, bromide 
of potassium and trionol have little effect. 

Aside from the treatment of tetanus in the newborn by means of 
drugs, the treatment by means of tetanus antitoxin should be re- 
sorted to in every case, in spite of the fact that failures have 
been recorded by Heubner, Leyden, and Blumenthal. We should 
inject antitoxin as soon as symptoms appear, inasmuch as favorable 
cases have been reported by Tizzone, Behring, Engelman, Kohler, 
and others. The antitoxin is given by means of lumbar puncture. 
A puncture is made in the ordinary way in the lumbar region, as 
elsewhere described. Five cubic centimetres of cerebrospinal fluid is 
allowed to flow off. The syringe is then attached to the puncture- 



ICTERUS NEONATORUM. 211 

needle and 5 c.c. of antitoxin are injected. Another method is to 
inject half of the serum by lumbar puncture and the other half sub- 
cutaneously. 

The use of the tetanus antitoxins has not given satisfactory results 
in some cases, probably owing to the fact that tetanus is a symptom 
of advanced toxsemia of the nervous system. In such a condition 
the action of any antitoxin would be exerted too late to give perma- 
ment benefit. These patients being unable to swallow must be fed 
per rectum until the acute symptoms have subsided and deglutition 
is possible. 

XII. ICTERUS IN THE NEWBORN INFANT. 

The majority of newborn infants are icteric. Icterus in the 
otherwise normal newborn infant should be differentiated from that 
due to sepsis, syphilis of the liver, cirrhosis of the liver, stenosis of 
the common bile-duct, and yellow atrophy of the liver. Acute 
yellow atrophy of the liver in the mother during pregnancy may 
produce an icteric condition in the newborn infant. 

Icterus Neonatorum. 

An opportunity is rarely afforded to inspect postmortem the vis- 
cera of cases of icterus neonatorum, since recovery ensues in the 
majority of cases. In cases Avhich have come to the autopsy table, 
all the internal organs, including the bones and cartilages, were 
icteric. The spleen and kidneys were but little affected, even in 
severe forms, by the general icteric discoloration. In rare cases the 
liver was microscopically jaundiced. The intima of the arteries, the 
fluids in the serous cavities, the pericardial fluid, and the subcuta- 
neous and intermuscular connective tissue have been found to con- 
tain bile-pigment and biliary acids (Birch-Hirschfeld). The con- 
tents of the gut were normal. The kidneys contained uric acid 
infarctions. 

Etiology. — Icterus neonatorum is as frequent in institutions as 
in private practice. It is more common among boys (Kehrer). It 
is seen in premature weak infants, and in those whose birth has 
been attended by complications. The disease is now traced to both 
a hsematogenous and a hepatogenous source. There are certain 
processes in the blood which also involve the functions of the liver. 
According to Hofmeier and Silbermann there is a disintegration of 
red blood-cells in the circulation. These disintegrated red blood- 
cells are converted by the liver cell into biliary pigment ; the solids 
of the bile are increased, as is also the gross quantity of bile (Min- 
kowski, Naunyn, Stadelmann). It is not known, however, how 
this increase of bile-pigment gains access to the circulation. One 



212 THE DISEASES OF THE NEWBORN. 

theory (Silbermann) is that with the processes described above cer- 
tain ferments are set free which cause circulatory disturbances in the 
liver. Stasis results in the bloodvessels, with consequent pressure 
on the biliary ducts. Resorption of bile thus follows. 

Symptoms. — Fully 80 per cent, of all newborn infants become 
jaundiced shortly after birth (Runge). The jaundice appears on the 
second or third day after birth. The icterus may be slight and 
involve only the face, breast, and back, or may be severe and ex- 
tend over the whole trunk. In severe forms icterus of the con- 
junctivae is present. In this feature icterus neonatorum differs 
from ordinary catarrhal icterus, in which icterus of the conjunctivae 
is the first symptom before the skin is perceptibly tinged. The con- 
junctivae are last to be tinged in the jaundice of the newborn. 
Infants suffering from icterus, though in an apparently normal con- 
dition, do not increase in weight as normal infants do, and may 
even lose ground. When they recover lost weight, they do so 
slowly. 

The urine is brownish at times and contains biliary pigment and 
acids (Cruse, Hofmeier). 

Treatment. — Icterus, neonatorum, if untreated, disappears in 
three or four days in mild cases ; severe cases are more protracted. 
Neither form needs special treatment. 

XIII. THE OCCURRENCE OF HEMORRHAGES IN THE 

NEWBORN. 

Hemorrhages in the newborn are frequent as a result of infec- 
tion. These hemorrhages may accompany ordinary septic infection 
and form part of the symptomology of sepsis ; or they may as- 
sume a characteristic symptom -complex, and, as such, make up a 
definite picture corresponding to what has been formerly described, 
and still retained in the text-books for the sake of lucidity, as 
melaena neonatorum, Winckle's disease, and Buhl's disease. Hem- 
orrhages in the newborn may occur from the nose, the mouth, the 
conjunctiva, the umbilical wound, the stomach, the intestines, the 
vagina, the skin, and into most of the internal organs. The causes 
of such hemorrhages are either congenital haemophilia, or an under- 
lying dyscrasia, such as syphilis, or septic infection. A congenital 
haemophilia is rare and plays but a minor role in the causation of 
hemorrhages in the newborn. Grandidier records only 12 of 575 
cases of hemorrhage caused by haemophilia. In syphilitic infants 
hemorrhages may occur from two to three days after birth, either 
underneath the skin, from fissures in the skin, from the stomach, 
the intestines, or the internal organs. Some contend that in these 
syphilitic infants, in addition possibly to some infection, there is a 
change in the arteries ; others, deny that such changes exist^ and 



HELENA NEONATORUM. 213 

contend that the arterial changes described by Mracek are found in 
the normal infant (Fischl). I have seen FischFs preparations and 
must support his views. Inasmuch as these syphilitic infants come 
into the world as weaklings, and are on this account susceptible to 
infection, it is more rational to suppose that if hemorrhages occur 
they are the result of septic infection. Sepsis, therefore, is the main 
factor in the causation of all hemorrhages in the newborn. The 
clinical symptoms of these hemorrhages and accompanying constitu- 
tional disturbances will be described under the sections devoted to 
them. Some forms of hemorrhage have been considered in the sec- 
tions which treat of sepsis of the newborn, diseases and infection 
of the umbilical wound, and structures. The remaining forms 
will now be described, and for the sake of lucidity the early 
nomenclature is still retained. 

XIV. MELiENA NEONATORUM. 

This is a disease of the newborn characterized by a discharge of 
blood from the rectum and by vomiting of blood. It is a rare 
affection, occurring about once in 1000 births (Kling, Genrich, 
Runge). The hemorrhages occur in two distinct conditions : 

(a) As a symptom of a constitutional dyscrasia. This condition 
has been treated of under the headings of Hemorrhagic Congenital 
Syphilis, Sepsis, and the Acute Fatty Degeneration of the Newborn. 
Runge has shown that not only may the diseases named cause 
melsena, but that any of the infectious diseases of the newborn 
may give rise to this condition. 

(6) The second condition in which melsena occurs is that in which, 
as Landau, in his monograph on this disease has shown, local lesions, 
such as erosions and ulcerations resembling ulcus ventriculi, exist in 
the stomach and gut of the newborn infant. Hecker, Spiegelberg, 
and others have also described these ulcers of the stomach which 
produce the symptoms of melsena. Landau attributes the ulcer to 
embolism resulting from a thrombus of the umbilical vein or the 
ductus Botalli. Embolism in any artery of the mucous membrane 
of the stomach gives rise to necrosis and erosion, with the opening 
up of some arterial branch. Ingenious as this theory is, it is 
not accepted unreservedly by all, although Landau has proved 
the presence of emboli in the vicinity of stomach ulcerations. 
Another theory ascribes the ulcerations to hypersemia of the mucous 
membrane in asphyxia and traumatism. 

Melsena neonatorum can be caused not only by a coccal sepsis, 
but by a bacillary infection, as shown by Gartner, who found a 
bacillus in the faeces, and in the hemorrhages from the various 
organs and peritoneum. In other cases it is very probable other 
microorganisms will be found to have caused the sepsis. 



214 THE DISEASES OF THE NEWBORN. 

In addition there are cases in which no cause can be found to 
account for the symptoms. 

Morbid Anatomy. — Postmortem examination shows the gastro- 
enteric tract to be filled with dark hemorrhagic masses. The 
mucous membrane may be normal, the seat of erosions of greater or 
lesser extent, or there may be hemorrhagic areas scattered through- 
out the gut. These may be confined to the stomach or duodenum. 
There may be true ulcers of the stomach measuring J to 2 cm. in 
diameter, resembling those seen in the adult (Winckel). In some 
cases the thrombosed or eroded vessel is found in the floor of the 
ulcer or in its vicinity. All the organs are anaemic, and if syphilis 
or some other general disease exists there are the changes found in 
these conditions. 

Symptoms. — From two to four days after birth it is noticed that 
the infant is somnolent or restless ; there may be hemorrhagic stools 
or vomiting of bloody masses, or both these symptoms may be pres- 
ent at the same time. The principal symptom, however, is the 
bloody stools. These are at first mingled with meconium, and later 
become frequent and profuse. The vomited matter consists of 
mucus streaked with blood, or masses of blood of brownish color. 
The amount of blood lost by the bowel within twenty-four hours 
may be quite great. Under these conditions death ensues within a 
period of from twelve to twenty-four hours, with all the symptoms 
of acute anaemia. In other cases there may be a cessation of the 
intestinal hemorrhage for from twenty-four to forty-eight hours, but 
recovery does not always take place, and sudden death from a severe 
hemorrhage may occur at any time. 

The prognosis is grave. Sixty per cent, of the infants aifected 
die. The outlook is more serious in conditions of sepsis, syphilis, 
and acute fatty degeneration than in melsena due to ulcer of the 
stomach or duodenum. 

Diagnosis. — We must differentiate this disease, which is called 
true melsena, from the so-called spurious form, in which the infant 
simply passes blood swallowed with the food. This spurious form 
may occur if the breast nipple is fissured or if there is a fissure of 
the anus. In other cases blood from the nose or mouth of the 
infant may be swallowed. Hemorrhages of this kind may occur as 
part of a general septic infection. In many cases there may be, with 
other hemorrhages, icterus, cyanosis, oedema, pointing to some gen- 
eral disease. Sensitiveness in the region of the stomach points to 
ulceration of this organ. 

Treatment. — The hemorrhages should be controlled by the appli- 
cation of a cold coil to the epigastrium and the administration of cold 
drinks. Henoch recommends a drop of liquor ferri sesquichloridi 
every hour in barley-water. Ergotin is given in doses of J to f 
grain internally or subcutaueously. Suprarenal extract has been 



ACUTE FATTY DEGENERATION OF NEWBORN INFANT. 215 

administered in some cases which have recovered, and may be tried. 
In a case coming under my care adrenalin was of no avail. Enemata 
are not advisable. The heart is stimulated with strychnine, digitalis, 
camphor, or ether. 

XV. ACUTE FATTY DEGENERATION OF THE 
NEWBORN. 

{BuhVs Disease.) 

This disease, first described in 1861 by Buhl, is an acute paren- 
chymatous fatty degeneration of the liver, kidney, or heart, combined 
with hemorrhages into the various organs, or from the umbilicus, 
intestines, or stomach. 

Etiology. — The disease occurs in the lower animals, especially 
in sheep. In the human subject it is a form of septic infec- 
tion, although in Buhl's cases the vessels of the umbilicus had a 
normal appearance. Septic infection may occur without any appre- 
ciable changes about the umbilicus or elsewhere on the surface of the 
body (cryptogenetic). The disease is very rare ; many cases described 
as omphalitis and hemorrhage from the umbilicus probably belong 
to the category of Buhl's disease. 

Morbid Anatomy. — The body is icteric or cyanotic ; there is 
oedema of the surface, and not infrequently hemorrhagic areas in the 
skin. The umbilicus may be covered with blood, but the vessels 
and wound are otherwise normal. Hemorrhages or petechise are 
found in most of the internal organs, especially the pleura, pericar- 
dium, mediastinal tissue, muscles, and mucous membranes. The 
heart is the seat of fatty degeneration, as is also the liver, which is 
enlarged. The spleen is enlarged and soft. The kidneys are the 
seat of fatty parenchymatous changes. The stomach and intestines 
are filled with blood. There are hemorrhages into the mucous 
membrane of the stomach and intestine. The intestinal villi are the 
seat of fatty degeneration. 

Symptoms. — The children are born partially asphyxiated. At- 
tempts to resuscitate them are not fully successful. Some die in 
asphyxia, others after a time have bloody diarrhoeal stools. At 
times there is vomiting of blood, and when the stump of the cord 
separates there is hemorrhage from the umbilicus. The bleeding from 
the umbilicus is parenchymatous, and may be so profuse as to cause 
death. The skin is at first cyanotic, then icteric in hue. Large 
hemorrhagic areas appear in the skin, conjunctivae, and mucous 
membrane of the mouth, and bleeding may occur from the ear and 
nose. Icterus may become extreme. At times oedema of the sur- 
face appears. The temperature is not raised. Death ensues in 
collapse. The external hemorrhages and icterus are absent in some 
cases. 



216 THE DISEASES OF THE NEWBORN. 

Diagnosis. — In the newborn infant this symptom-complex is 
unique, and must be looked upon as a form of sepsis, either through 
the umbilicus or through some other avenue. In the newborn 
infant this disease may be confounded with death from asphyxia. 
In all cases of medico-legal import the organs should be examined 
for parenchymatous changes before an opinion is given. 

Prognosis. — The disease is fatal. 

Treatment. — The physician endeavors to bring the infant out 
of the state of asphyxia. It can be easily understood that he is 
helpless in the face of the parenchymatous hemorrhages and degener- 
ations, for which there is at present no remedy. 

XVI. WINCKEL'S DISEASE. 

{Epidemic Hcemoglobinuria of the Newborn.) 

This disease, first described in the epidemic form by Winckel, is 
characterized by the sudden appearance of cyanosis and icterus with 
hsemoglobinuria. 

Etiology. — The etiology of the affection is obscure. Epstein, 
Strelitz, and Baginsky consider the disease a form of septic infection. 
WinckeFs cases were believed to be due to the use of infected drink- 
ing, or bath, water. Birch-Hirschfeld and Strelitz found streptococci 
in the various organs and the blood. Kamen, in an epidemic of the 
disease, found the colon bacillus in the capillary bloodvessels and 
various organs. 

Morbid Anatomy. — Postmortem examination reveals no disease 
of the umbilicus or umbilical vessels. The kidneys are the seat 
of cortical hemorrhages. The spleen is large and hard, and filled 
with pigment. There are punctate hemorrhages in almost all the 
organs, especially in the pleura, pericardium, and endocardium. 
Hemorrhages are present in the mucous membrane of the stomach 
and gut, and underneath the liver capsule. Peyer's patches, solitary 
follicles, and mesenteric glands are enlarged. The liver, heart, and 
various organs show fatty degeneration. There are bacterial foci 
in the liver and kidneys. The blood shows an increase in the 
leucocytes and in the free granules. 

Symptoms. — The symptoms in Winckel's cases appear on the 
fourth day after birth in apparently healthy and well-developed 
infants. The average duration is thirty-two hours. Some infants 
succumb in nine hours after the onset of symptoms. Restlessness 
and cyanosis are first noted. The latter is general, affecting the 
trunk and extremities. Icterus then develops, and becomes marked 
within twenty-four hours. The respiration and pulse are accel- 
erated ; the temperature may be normal, 38° C. (100.5° F.) ; the 
skin is cool. At tim6s there are vomiting and diarrhoea. The urine 
is passed with tenesmus, brownish in color, and contains blood- 



SCLEREMA. 217 

cells, haemoglobin, renal epithelium, granular casts, micrococci, 
detritus, and ammonium urate. Convulsions close the scene. If 
the skin is cut, a brownish syrupy fluid exudes. 

Diagnosis. — Owing to the similarity of symptoms, WinckeFs 
disease may be confounded with BuhPs disease. The former pursues 
a very malignant course, and does not present the intestinal and 
stomach hemorrhages to the same extent as the latter. 

Runge and others are inclined to believe that all these hemor- 
rhagic aifections are due to a common cause — septic infection. The 
hasmoglobinuria is simply a marked hemorrhage into the kidney. 
Parenchymatous fatty degeneration of the various organs is common 
to both affections. 

Prognosis. — The prognosis is fatal. 

Treatment. — The treatment is that of sepsis of the newborn. 

XVII. SCLEREMA. 

{Sclerema Neonatorum ; Sderoedema Neonatorum ; Sclerema Adiposum. ) 
This peculiar and rare affection is apt to be confounded with 
ordinary oedema. There are two forms of this condition : one form 
called sderoedema, or oedematous sderoedema of Soltman ; the second 
form is called sclerema adiposum, or fat sclerema. 

Sderoedema (Soltman). 

This affection is not so rare in institutions on the continent of 
Europe, although in this country it is uncommon. It is not as com- 
mon a disease as fat-sclerema, which will be described later. It is a 
disease of the newborn, and occurs only in the first days of life. 
Some children, according to Dennis, Billard, and Demme, are born 
with the disease. In these cases the children are born cold, stiff, 
cannot move, the surface is swollen, oedematous, tense, a great extent 
of surface being involved in most cases ; and in some cases even an 
ascites is present. In some, however, the feet are first swollen, then 
the whole body becomes involved later on. Most of the cases 
published have been fatal in from a few hours to a few^ days after 
birth. The form seen after birth occurs mostly in premature infants, 
or in the congenitally weak infant, one of twins or triplets, or in 
infants with a syphilitic history. The disease usually begins four 
days after birth, or may appear as late as the tenth day or in the 
third week. These children, as stated, are mostly underweight and 
congenitally weak. 

Etiology. — The etiology of sderoedema, or acute oedema, is still 
a matter of speculation. Weakness of the heart, a beginning 
nephritis, or an infection of some kind, deficiencies in circulation 
and respiration in premature infants, unhygienic surroundings — all 
have been advanced to explain this rare condition. In the secondary 



218 THE DISEASES OF THE NEWBORN. 

form, the so-called sclerema adiposum, there is to a certain extent 
a desiccation of the subcutaneous tissues. Sanger thinks that the 
excess of palmatin and stearin in the subcutaneous fat of the new- 
born infant may account for the peculiar solidification, since the 
temperature is reduced, as it is in fat-sclerema. There are cases of 
fat-sclerema in which the temperature, as has been stated, is elevated. 
Such was Barker's case, and I have recently seen such a case, so 
that the theory of Sanger is scarcely adequate. The cases of fat- 
sclerema which I have seen have created in my mind the impression 
of an infectious condition ; though this etiology is denied by most 
investigators. Barker found streptococci in the internal fluids after 
death. 

Symptoms. — There are no prodromata, except possibly an uneasi- 
ness on the part of the infant, or dryness and coldness of the surface. 
The respirations are superficial ; the temperature, which falls in most 
infants after birth, does not return to the normal. When the 
symptoms are fully developed they are seen first in the lower extrem- 
ities, in the calves of the legs and the dorsum of the feet, spreading 
thence to the thighs and involving the suprapubic fat. Earely the 
eyelids and both upper extremities are involved. The skin is 
oedematous, swollen, and much thickened. In some cases the skin 
does not pit on pressure ; in others the pitting takes place, but the 
skin rapidly returns to the primary condition. The color of the 
skin is either reddish, if the scleroedema has appeared before the 
process of desquamation is complete ; whitish, if the desquamation of 
the skin has been completed ; or cyanotic, if the infant is premature. 
As the disease progresses the skin becomes more oedematous, of a 
yellowish, transparent color, and in the first form tlie redness of the 
skin disappears. In the cyanotic form the cyanosis increases, the 
skin assumes a bluish, marbled appearance. In the worst forms the 
skin is so tense that pitting by means of pressure with the fingers 
does not occur, or immediately disappears when the pressure is 
released. If the skin is punctured with the needle, there is an 
escape of fluid or yellowish serum. These infants take the breast 
badly. They sometimes emit a peculiar, shrill cry, due, it is sup- 
posed, to oedema of the vocal cords. 

The temperature in the mild forms may range from 34° to 35° 0. 
(93.2°-95° F.) ; in severer forms, from 30° to 32° C. (86-89.6° F.), 
but rarely as low as in fat-sclerema, where it may be 22° C. (71.6° F.). 
A complicating pneumonia, however, may cause a rise of the temper- 
ature either to the normal limit or even as high as 41° C. (105.8° F.). 
The heart is weak ; the pulse may have a frequency as low as sixty 
a minute, and in some cases is not perceptible at the wrist. The 
respirations are superficial, labored, and slow. The urine contains 
albumin, sometimes sugar, and, if the infant is icteric, bile pigment ; 
it may also contain red blood-cells, granular casts, and fatty epithe- 



SCLEREMA ADIPOSUM. 219 

lium, and rarely leuciii. The disease in most cases is confined to 
the lower extremities, the mous veneris or suprapubic fat, and 
buttocks and lower part of the back, but it may spread around to 
the abdomen, involving its lower part. It seldom occurs in patches 
or small areas. If improvement occurs, the oedema may disappear, 
leaving a condition of the skin resembling fat-sclerema. Under 
these conditions the skin is less wrinkled and oedema of the deeper 
parts disappears slowly. In fatal cases death supervenes without 
any marked symptoms. The infants simply fail, the pulse becomes 
slow, the respiration ceases ; children die in apathy and coma. 

Duration. — Congenital cases may die in a few hours ; the post- 
natal may linger from four days to two weeks. Complications are 
rare ; they have nothing in common with the primary disease, and 
result as a consequence of the reduced circulation and liability of 
these infants to infection. Hemorrhages occur in the lung and pleura ; 
lung complications may occur. Effusions have been found in the 
peritoneum and pleura ; the latter especially in congenital cases. 
The skin may be the seat of icterus, pustules, ulcers, erysipelas, 
purpura, or gangrene, especially if complicating sepsis is present. 
Decubitus ulcers, ecchymoses, and finally pneumonia may occur as a 
septic complication. 

Morbid Anatomy.— So far as the skin is concerned, the oedema 
post mortem is much the same as daring life. The skin, muscles, 
and cellular tissue, not only of the skin, but of the various regions, 
such as the mediastinum and vocal cords, are involved. In fatal 
cases there has been found intestinal catarrh, affections of the lung, 
such as atelectasis ; bronchitis, bronchopneumonia, pleurisy, myocar- 
ditis, fatty degeneration of the liver, spleen, and kidneys, hemor- 
rhages into the lung and tissue of the heart. 

Prognosis. — Clementowsky, who has made a close study of this 
disease, has recorded 152 cases with 52 deaths. The presence, 
therefore, of this disease does not exclude the possibility of a recovery, 
provided the infant retains a certain amount of constitutional resist- 
ance and the disease is not widespread. 

Treatment. — The treatment of this form of scleroedema being 
much the same as that of fat sclerema, both will be treated under a 
common heading. 

Sclerema Adiposum. 

{Fat-sclerema.) 

This condition is much more common than the scleroedema just 
described, and is not a disease confined entirely to the first days of 
life, but may occur up to the sixth month of infancy. It is doubt- 
ful if the disease occurs as a congenital condition. If so, it is rare. 
The affection follows or complicates exhausting diseases, and is also 



220 THE DISEASES OF THE NEWBORN, 

seen complicating summer diarrhoea, cholera infantum, and pneu- 
monia. If seen as a complicating condition, it is a forerunner of 
death. It may be seen not only in bottle-fed, but also in the breast- 
fed infant, the victim of these affections. 

Symptoms. — The disease itself begins mostly in the calves 
of the legs, but not exactly where the loose connective tissue 
exists, as the scleroedema does. The deeper parts are firm; the 
skin is not movable, and has a doughy feel, as though there were 
nodules of fat imbedded in the tissues. Another place of pre- 
dilection of its appearance is in the face, where it is first seen 
affecting either the tip of the nose or the cheeks. The affection is 
symmetrical. It appears, as has been stated, in the calves, involves 
the dorsum of the feet, spreads to the thighs, involves the buttocks, 
especially the inner parts of the thighs, may spread to the upper 
extremities, lastly involving the face. The palms of the hands or 
soles of the feet, even in the severest cases, remain free ; as also the 
scrotum and penis. The skin, when the disease is fully developed, 
is flat, shining, tense, closely adherent to the subadjacent parts, or it 
may be of a yellowish, whitish, lardaceous appearance, or may be 
ecchymotic, cyanosed, or red in areas. When the skin is palpated 
it has a doughy feel, very much as is seen in a corpse. The skin 
has lost all its original resiliency. In some cases pitting on pressure 
may result, but not to the extent seen in scleroedema. In some 
cases, where the disease has extended over a large surface, the body 
may be taken up and will remain stiff and extended like a corpse. 
The respirations are very shallow and reduced in frequency, 16 to 
18 a minute. The heart is weak, its frequency reduced from 80 to 
60 or even 30 beats a minute. The temperature is low (much lower 
than in the scleroedematous form). It may fall to 30°, 26°, or even 
22° C. (86°, 78.8°, or 71.6° F.). If a" complicating infection is 
present, such as pneumonia, the temperature may rise to near the 
normal. The urine is diminished in quantity, dark, concentrated, 
contains albumin, casts, urates, and uric acid. If there is a com- 
plicating condition, it is generally one of the exhausting diseases, 
such as summer diarrhoea, cholera infantum, or septic pneumonia. 
Exitus lethalis, as in the previous form, takes place under conditions 
of progressive failure of the respiration, reduction of temperature, 
failure of the heart, unconsciousness, and coma. 

Morbid Anatomy. — The skin and subcutaneous tissues post 
mortem retain the characteristics seen during life. If cut into, no 
fluid exudes, and very little bathes the surface of the section as com- 
pared with what is seen in scleroedema, where considerable fluid exudes 
from the cut surface. The tissues are (dry very much like frozen 
fat). Atelectasis, pneumonia, oedema of the lung, pleuritis, peri- 
carditis, hemorrhages, enlarged spleen, and fatty degeneration of the 
liver and kidneys may be present as complicating conditions, with 



OPHTHALMIA NEONATORUM. 221 

or without intestinal catarrh. In the brain, hyperaemia and hemor- 
rhages have been recorded. 

Duration. — The duration of the disease is from two to seven days. 

Diagnosis. — To diagnose either of these forms from the symp- 
toms just detailed is not difficult ; but I have seen it mistaken for 
the oedema of nephritis. On examination such a mistake can easily 
be rectified, for in nephritis certain features of sclerema are absent, 
such as reduction of temperature, lardaceous, corpse-like feel of 
the skin, the lack of resiliency, especially in the fat sclerematous 
form. In infants the skin may even retain its original wrinkled 
appearance, and the deeper tissues of the skin have the character- 
istics described. On the other hand, nephritis may complicate 
scleroedema or fat-sclerema. 

Sclerema must not be confounded with a similar disease which 
occurs in the adult subject and older children. Sclerema of the 
newborn and scleroedema do not appear, as in the adult, in patches, 
but involve whole regions and extremities. This condition of the 
newborn must not be confounded with sclerodactylia, which is seen 
in adults and older children. 

Prognosis. — The prognosis of fat-sclerema is not necessarily 
fatal, if primary and not complicated with any exhausting condition ; 
if secondary, as has been stated, it is the forerunner of death. 

Treatment. — Inasmuch as these infants have not only a reduced 
temperature, but a tendency toward a constant progressive reduction 
of the internal temperature, they should be put in some form of in- 
cubator, and the same methods applied as in the care of premature 
infants. Oxygen is administered to stimulate not only the respira- 
tions, but the heart. If the sclerema is not too general the parts 
may be massaged with camphorated oil ; and I have seen some cases 
in which a decided improvement followed such treatment. Cardiac 
stimulants are used to arouse the flagging circulation. The best 
drugs to employ are caifein and strychnin, with or without ammo- 
nium carbonate. To these infants w^e must give very small doses, 
J grain of citrate of caffein every few hours, or -g-J-Q; grain of strych- 
nin, or I grain of ammonium carbonate. In many of these cases 
the act of nursing is impossible, and they must be fed with the 
pipette. If unable to swallow they must be fed per rectum. The 
subcutaneous injection of fluids, in my hands at least, has been of no 
avail ; therefore the hypodermoclysis is of very little utility. 

XVIII. OPHTHALMIA NEONATORUM. 

( Conjunctivitis JBlennorrhceica. ) 

Ophthalmia neonatorum is an inflammation of the conjunctiva, 
accompanied by a profuse secretion of pus, and in some cases an 
inflammation of the cornea, It is a specific inflammation of the 



222 THE DISEASES OF THE NEWBORN. 

conjunctiva due to the gonococcus of Neisser. From 30 to 40 per 
cent, of the children in the institutions for the blind have lost their 
sight through this disease. 

Etiology. — The infant may be infected during labor or after 
birth. It may be infected immediately after birth, or some time 
subsequent to delivery. In those cases in which the disease appears 
from twelve to twenty-four hours after birth, they may be safely 
said to have been infected in the passage through the parturient 
canal. In those cases infected after birth the symptoms appear in 
from three to four days post partum. Finally, children may be 
infected at any period in the puerperium. 

The sources of infection are the secretions from the parturient 
canal of the mother, or infectious material conveyed to the eyes of 
the infant by the finger of the nurse or accoucheur. The infection 
post partum occurs by direct contact of the gonococci with the 
orbital conjunctiva. In institutions, infections are ten times as 
frequent as in private practice, where the disease, at least on the 
continent of Europe, occurs in 0.1 per cent, of births (Silex). 

Symptoms. — From three to five days after birth it is noticed 
that the conjunctivae are red and swollen ; there is an injection of 
the sclera, swelling of the lids, and increased temperature of the 
parts, or possibly oedema and profuse secretion, at first of a thin, 
yellow, serous discharge, which after two days becomes thick and 
creamy. The swelling of the lids is quite marked ; the eyes are 
closed. In some cases the palpebral conjunctiva protrudes from 
between the orbital fissure and a profuse creamy pus exudes from 
between the eyelids. If the child has icterus, this pus may assume 
an icteric color. The cornea is hazy, covered with secretion, and 
shreds of pseudomembrane may adhere to the palpebral conjunctiva, 
especially in the early stages of the disease, thus simulating diph- 
theritic infection. If not controlled the inflammation of the eye 
progresses until the whole depth of the cornea is involved, resulting 
in perforation and prolapsus of the iris, escape of the humor, and 
consequent panophthalmitis. The constitutional symptoms in these 
cases consist of a lack of desire to nurse on the part of the infant, 
and a slightly elevated temperature. If the infant is premature or 
the subject of any dyscrasia, the constant chilling which takes place 
as a result of cold applications to the eyes results either in a loss of 
or stationary weight. Therefore this disease is more serious if it 
occurs in bottle-fed than in breast-fed infants. 

Duration. — The duration of the disease varies according to the 
intensity of the infection. As a rule, it lasts three or four weeks, 
when it becomes subacute, and the secretion changes to a mucoid or 
serous character. 

Complications. — The complications, so far as the eye are con- 
cerned, are keratitis, with perforation of the cornea and loss of the 



OPHTHALMIC NEONATORUM. 223 

eye. In some cases arthritis of a gonorrhoeal nature has been 
recorded as a complication ; in others, vulvovaginitis may result as a 
complicating infection. 

Diagnosis. — The diagnosis presents no difficulties. There is a 
simple inflammation of the eyes occurring in newborn infants which 
is not gonorrhoeal in its nature, but in which the local symptoms are 
not very marked ; in fact, so mild as to raise a suspicion at once 
of its non-specific nature. In other cases of ordinary non-specific 
conjunctivitis, chemosis, swelling, and oedema of the lids are not 
marked as compared to what is seen in the gonorrhoeal form. The 
amount of pus secreted is not great, and the course of the disease 
is, as a rule, benign. We should, however, before deciding as to 
the innocent nature of a conjunctivitis in the newborn make a 
spread of the pus on a cover-glass and stain the same for gonococci, 
as this is the only certain method of determining the nature of the 
disease. In doubtful cases a culture will be demanded. Clinically, 
however, the two forms of conjunctivitis are so distinct that w^e 
may suspect the one or the other from the mildness or the severity 
of the local symptoms. 

Prognosis. — The prognosis is grave in all cases. A favorable 
issue will always depend on an early recognition of the disease. 
If the disease is recognized late in its course, the prognosis becomes 
not only doubtful, but grave as to the integrity of the organ. 

Treatment. — The physician will understand that above all 
things cleanliness is the first factor in the prevention of this dread 
affisction. In private practice, we will always be able to judge, 
from a knowledge of the patient and her previous condition, as 
to the necessity of certain measures, which will be mentioned. 
If we are cleanly, however, some authors insist that not only in 
private practice, l3ut in institutions, the severer methods of prophy- 
laxis will remain superfluous. We may state that the principal 
method of prophylaxis in the past, and at the present day, is 
the so-called Crede method of prophylaxis of gonorrhoeal oph- 
thalmia, and this consists in the instillation of a drop of a 2 per 
cent, solution of nitrate of silver into the eye immediately after 
birth. In ordinary cases of head presentation it is contended that 
if the parts of the mother are cleansed just before the birth of the 
head, and if after the head is born the eyes are carefully but ener- 
getically w^ashed with sterilized water, better results are obtained 
when large numbers of cases are treated than by the Crede method. 
Therefore, although in institutions it may be advisable to apply the 
Cred^ method, on account of the number of cases which are there 
treated, it is insisted that in private practice this method remains 
superfluous. A small dish of sterilized water should be close by, 
and while one hand supports the crowning head the other should 
wash the eyes carefully with the sterilized water before the child is 



224 THE DISEASES OF THE NEWBORN. 

born, and the complete washing of the eyes can then be repeated 
after the birth of the child. By this, the Kaltenbach, method of 
procedure only 0.3 per cent, of cases to the thousand are infected : 
whereas the combined results of the Crede method have not been 
lower than 0.6 per cent, per 1000, on account of the various 
methods of carrying out the Crede procedure ; though Crede him- 
self obtained as low a percentage as 0.1 in 2000 cases. 

The disease once inaugurated, the following treatment may 
be formulated : The eyes are cleansed, every half-hour to an 
hour, with a 1 : 1000 solution of corrosive sublimate. The eye is 
opened, and with dry cotton the excess of secretion removed, and 
then the remaining secretion washed away with the sublimate solu- 
tion. Small pieces of lint, cut to a size slightly larger than the 
eye, are kept on ice and applied every two to five minutes. The 
child is kept warm ; otherwise with this treatment the body may 
become chilled. A solution of 2 per cent, nitrate of silver is 
dropped into the eye daily. Later, when the secretion of the pus 
lessens and the conjunctiva is swollen and spongy, a 5 to 10 per 
cent, silver solution is dropped into the eye and immediately neu- 
tralized with salt solution. Any therapy beyond that just outlined 
is scarcely within the province of the general practitioner ; but so 
important is immediate action in these cases that every practitioner 
should proceed with the treatment before calling to his aid an oph- 
thalmic surgeon. If one eye alone is affected, it is well to try to 
save the other eye from infection, and- there are several methods by 
which this may be accomplished. A simple method is to close the 
eye, cover it with cotton, enough to fill out the hollow of the eye, 
and then to cover this cotton with a piece of lint. Over this place 
a piece of gutta-percha protective, and bind the eye shut. Such an 
eye should be looked at daily before the affected eye is treated and 
cleansed. Should it become infected, the bandages are removed, 
and the eye treated in the same manner as the affected eye. 

XIX. CAKING OF THE BREASTS. 

Caking of the breasts of the newborn is not uncommon, and must 
not be looked upon as a necessary forerunner of mastitis (Fig. 23). 

If the breasts of the newborn are swollen but not very tense 
they should not be interfered with, as this is caused by an abundant 
milk secretion, which soon diminishes. No attempt should be made 
to express the milk. If milk exudes it should be carefully washed 
off the breast, and the breast protected from traumatism and infec- 
tion by a pad of dry sterilized gauze. In exceptional cases the 
breasts seem really tense and painful. Under those conditions they 
may be gently massaged once a day. The index finger of the right 
hand is cleansed, anointed with sterilized oil, and the breast is 



INJURIES INFLICTED DURING BIRTH. 225 

stroked in a circular direction for about five minutes. It is then 
cleansed and covered with cotton or gauze, as detailed above. It 
is not possible in the newborn to bandage the breasts tightly, as 
this procedure interferes with the respiratory movements of the 
chest. 

XX. MASTITIS. 

Mastitis in the newborn is the result of infection of the breasts. 
The organ of one or both sides becomes tense and painful, and the 
skin covering the breast becomes red or bluish-purple in hue. There 
are fever and restlessness. After a few days fluctuation appears in 
the breast, generally toward the base of the nipple. 

The treatment at first should be directed toward aborting or 
limiting the inflammation. Nothing is so eifective as the applica- 
tion of small squares of lint which have been moistened with a 
weak solution of sublimate, 1 : 10,000, and applied cold. If after 
a time fluctuation appears, incision and drainage are indicated. 



XXI. INJURIES INFLICTED DURING BIRTH. 

Among the injuries incident to birth are those of the face. 
Pressure of the forceps blade may cause facial paralysis. This, as a 
rule, disappears in time, though in severe injury of the nerves it may 
remain permanent. Indentations of the cranial bones may result 
from the pressure of instruments. In these cases the bone is 
depressed, and in the space between the scalp and bone there is an 
effusion. The edge of the bone surrounding the depression is 
distinctly felt. These depressions need no treatment, as they 
disappear in time. Traction on the arm may cause a so-called 
birth palsy, which is the counterpart of Erb's palsy in later life. 
The paralysis in these cases sometimes remains permanent. Others 
recover. As a rule, one arm is affected, but in rare cases both arms 
may be paralyzed. The symptoms are characteristic. In a few 
days or at a later period after birth it is noticed that the infant does 
not move one or the other arm (Fig. 28). The affected limb hangs 
loosely and without power of motion. The fingers or hands may 
be mobile. The affected arm is cold and the hand may be bluish 
in tint. After a time atrophy of the muscles about the shoulder- 
joint may set in. The bony prominences then come into relief. 
If the arm does not recover power, the muscles continue to atrophy, 
and there may be subluxation of the head of the humerus at the 
shoulder-joint. The child in these cases always holds the injured 
arm with the sound one, in order to protect and support it. At the 
early period the reactions of degeneration are present, and if the 
muscles recover, the reaction to the galvanic and faradic current 
15 



226 



THE DISEASES OF THE NEWBORN. 



becomes normal. If recovery does not take place, the disappearance 
of galvanic and farad ic irritability of muscle goes hand in hand with 
the muscular atrophy. 

The treatment of these obstetrical palsies is similar to that of 
Erb's palsy. The arm is protected from traumatism. Massage is 
performed within two weeks after injury, and after four weeks the 
faradic current is applied to cause muscular contraction. Electricity 
is applied for a short space of time daily. The progress of these 
cases can best be judged under treatment. As a rule, recovery 
takes place in a few weeks. In other cases recovery may be delayed. 
In a third set of cases recovery never takes place. The galvanic 

Fig. 28. 




Birth palsy affecting the left arm, atrophy of the muscles about the shoulder. 

and faradic contractility disappears from the muscle and nerve, and 
permanent atrophy and disability remain. In these cases there is 
also retarded growth of the bone. It may be mentioned that in rare 
cases pressure of the forceps blade has caused a paralysis of the hypo- 
glossal nerve and consequent paralysis of one or other half of the 
tongue. Every time the infant nurses there will be in such cases 
great difficulty in swallowing. The infant will cough and become 
cyanosed. These infants must be nursed slowly or with a pipette 
until the tongue has recovered power. 



PLATE VI. 




. Hsematoma of the Sternomastoid Muscle of the Right Side 
in a Newborn Infant. SweUing at the centre of the anterior 
border of the muscle ; contraction of the muscle >A^ith 
torticollis. 



CEPHALOHjEMATOMA. 227 

Hsematoma of the Sternomastoid Muscle. 

This affection is the direct result of traumatism during delivery. 
As a rule, it is seen in cases of breech presentation in which trac- 
tion has been exerted on the after-coming head. In the majority 
of the cases coming under my observation the sternomastoid muscle 
of the right side was affected (Plate YI.). The infant holds the 
head on one side. The muscle of the affected side is contracted, 
and the position of the head is that seen in torticollis. A hard 
nodule is felt along the inner border of the sternomastoid muscle, 
about the junction of the lower third and upper two-thirds. The 
tumor is usually the size of a small hazelnut, but may be much 
larger. Manipulation causes pain. The skin over the tumor is 
movable and not discolored. 

The progress of the affection in all of these cases is much the 
same. The tumor becomes smaller as the exudate is absorbed, but 
the torticollis persists, although in time this may disappear. The 
nature of these tumors is probably that of a hsematoma caused by 
rupture of muscular fibres and bloodvessels. 

The treatment is simple. At first the tumor should be let 
alone. After a few days gentle massage with the finger moistened 
with oil is permissible. When the growth hardens the massage may 
be more vigorous, and be supplemented with an attempt at each sit- 
ting to turn the head gently to the opposite side and thus stretch 
the contracted muscle. Cases which do not recover must be treated 
by surgical means later in life. 

Cephalohaematoma. 

Cephalohsematoma is an effusion of blood between the pericranium 
and the skull-cap. The pericranium and scalp are raised into a 
distinct tumor. In external cephalohaematoma the effusion is between 
the pericranium and the skull ; in internal cephalohsematoma it is 
between the dura mater and the skull. Kee found both forms pres- 
ent in the same patient in 9 out of 20 cases. 

Symptoms. — There is a tumor varying in size from that of a 
hazel-nut to that of an orange, of elastic consistency, situated in most 
cases on one or the other parietal bone. It is round, elongated, or 
kidney-shaped. It covers part or the whole of the bone, but never 
extends beyond the sutures. The skin over the tumor is not sensi- 
tive to the touch, is normal or slightly bluish in color, and is perfectly 
movable over the tumor. After a few days the circumference of the 
tumor is bounded by a distinct wall, at first soft, but later of bony 
hardness. The general health of the infant remains good unless 
there is a complication. This blood tumor appears two or three 
days after birth. At first it is tense, but afterward becomes softer 



228 THE DISEASES OF THE NEWBORN. 

and doughy to the touch. It reaches its maximum size in from 
six to eight days. It begins to diminish in the second week, and 
disappears by the fifteenth week. The tumor is either absorbed or 
there is a proliferation of bone, which remains as an exostosis. At 
this time crepitation resembling that of parchment is felt. Around 
the former tumor a thin wall of bone is found. 

Occurrence. — These tumors are not common. Henuig found 
230 cases in 53,506 births, or 0.43 per cent, of the whole number. 
Hofmokl's statistics give a like figure. Most of the cases are vertex 
presentations. The cephalohsematoma usually occurs on the right 
parietal bone, and may follow easy as well as difficult labors. It 
is present oftener in boys than in girls, and is seen in premature 
infants as well as full-term babies. It has been observed in breech 
cases, especially if forceps has been applied to the after-coming head. 
These tumors may occur on both parietal bones of the infant. In 
such cases the sagittal suture distinctly separates the two tumors. 

Complications. — Internal cephalohaematoma, or cerebral hemor- 
rhage, may complicate the external tumor. In such cases there has 
been a difficult labor with the application of forceps. The majority 
of the infants thus affected die. Suppuration of the tumor may take 
place, or diffuse cranial phlegmon may result fatally. A section of 
a cephalohsematoma shows the scalp to be studded with punctate 
hemorrhages. The pericranium is bluish and covered with hemor- 
rhages, and is separated from the skull by a collection of fluid blood 
under great tension. The bone beneath is rough or covered with 
a few clots. A bony wall is seen around the circumference of the 
tumor. It is a periosteal formation. After a time the bone and the 
inner surface of the pericranium become coated with a gelatinous 
exudate, which is subsequently converted into bone. In some cases 
quite an extensive bloody effusion is found between the dura and 
skull. 

The situation of the cephalohsematoma always corresponds to the 
position of certain natural fissures which exist in the posterior part 
of both parietal bones, running from the sagittal suture. In the 
occipital bone these fissures radiate from the lateral fontanelles and 
separate the upper and the inferior part of the occipital bone. 

Pathogenesis. — A cephalohsematoma is the result of the bursting 
of a small vessel between the periosteum and bone, and at the situa- 
tion of the caput succedaneum. Hence the frequent formation of 
the tumor on the right parietal bone. It is most common in first- 
born infants. Asphyxia of the infant favors the formation of the 
tumor. Cephalohsematoma may also occur as a part of the hemor- 
rhagic symptomatology in general diseases, such as syphilis, sepsis, 
and BuhPs disease. 

The diagnosis is made in the presence of an elastic fluctuating 
tumor distinctly limited by suture and surrounded by a ring or wall. 



CEPHALOHJEMATOMA. 229 

A caput succedaneum is oedematous and bluish, is seen immediately 
after birth, passes beyond the sutures, does not fluctuate, and disap- 
pears shortly after birth. A hernia of the brain does not fluctuate, 
grows tense when the infant cries, and shows respiratory fluctuations 
and pulsation. It can be reduced. Abscess of the scalp is painful, 
hot, and red ; the phlegmon spreads over the whole scalp and is 
accompanied by oedema of the whole region. If cerebral symptoms 
are present with a cephalohsematoma, they point to corresponding 
internal eflusion or cerebral hemorrhage. 

The prognosis is good if there is no internal tumor or cerebral 
hemorrhage, or if infection of the external tumor with resulting 
abscess does not occur. Even the latter, however, does not preclude 
the possibility of recovery. The prognosis is bad if the cephalo- 
hsematoma is part of a general hemorrhagic condition, as in syphilis, 
fatty degeneration, or sepsis. 

Treatment. — Uncomplicated cephalohsematomata are absorbed 

if let alone. If abscess occurs, the tumor should be opened under 

antiseptic precautions, evacuated, and the sac packed with iodoform 

gauze. 

On the other hand, even in the early stage, the tumor may be large and 
tense, and cerebral symptoms may be present. Such effusions of blood may 
communicate with an internal tumor through the parietal or occipital fis- 
sures mentioned. In such very exceptional cases aspiration to relieve internal 
j)ressure may be justifiable (Runge). 

References of Authorities for Collateral Reading. 

Bertin, G. : Infections des Nouveau nes dans le couveuse, Paris, 1899. 

Budin, P.: ''Le Noiirrisson," Paris, 1900. 

Escherich, T. : " Trismus et Tetanus," Wien. klin. Wochenschr., 1893. " Brut- 
kammer fiir friihgeborenen," etc., Mittheil. Vereins Steiermark, No. 3, 1900. 

Fischl, R. : " Infection Septiqne," Traite Maladies des Enfants, Comby, 1896. 
Prophylaxe der Krankheiten des Kindesalters, Nobling, Jankau, 1900. 

Landau, L. : Melaena der Neugeborenen, Breslau, 1874. 

Lange, 31. : Physiol. Path. u. Pflege des Neugeborenen. 

Moschowitz, A. V. : "Tetanus," Annals of Surgery, 1900. 

Pascaud, V. : La Couveuse Artificielle, Paris, 1899. 

Runge, M. : Die Krankheiten der Ersten Lebenstage, 1893. 

Voorhees, J. D. : " Care of Premature Babies in Incubators," Arch, oi Pediai., 
May, 1900. 



SECTION IV. 

THE SPECIFIC INFECTIOUS DISEASES. 

THE EXANTHEMATA. 

The exaDthemata, scarlet fever, roeasles, Rotheln, varicella, and 
variola, are acute specific infectious diseases. They form a distiuct 
group. The poison or infectious element originates in the body 
of the patient. The nature of this poison is unknown. Though 
suspected to be bacterial, the essential cause in any of the exan- 
themata has not been isolated. We do know, however, that the 
acute exanthemata are conveyed from one person to another through 
the medium of the atmosphere. In this respect they diifer essentially 
from such diseases as typhoid fever, or even syphilis, in which the 
morbific agent must be introduced into the body. They are there- 
fore contagious in the true sense of the term. Most people are sus- 
ceptible to some of the exanthemata, such as measles and smallpox. 
On the other hand, not every one exposed to contagion will contract 
scarlet fever or varicella. Few persons are attacked twice by the 
same exanthematic affection, but there are exceptions to this rule. 
An attack of one disease, such as measles, does not confer immunity 
from an attack of another, such as scarlet fever. The exanthemata 
occur either endemically or epidemically. Each has a well-defined 
period of incubation — that is to say, an interval between the time of 
the exposure to contagion and the onset of characteristic symptoms. 
In the different exanthemata this interval varies within wide limits. 
The period of incubation seems to be more accurately determined in 
measles than in the other exanthemata. It is well established that 
two of the exanthemata may occur at the same time in the same sub- 
ject. This is not a point in favor of the identity of the essential 
cause of the exanthemata. On the contrary, it is an accepted fact 
that each of the exanthemata is distinct in itself, and that each dis- 
ease has its specific essential cause. The exanthemata are character- 
ized by an eruption on the skin, the so-called exanthema, or rash. 

I. SCARLET FEVER. 

Scarlet fever is an acute infectious disease with a characteristic 
rash or exanthema. It is highly contagious. 

Etiology. — It has not as yet been established whether the infec- 

231 



232 THE SPECIFIC INFECTIOUS DISEASES. 

tious agent is a micro-organism, although streptococci have been 
isolated from the secretions and scales in the desquamative period. 
Neither do we know whether there is an organism, a protozoan, in 
the circulating blood. The atmosphere about the patient seems in 
most cases to be the zone of contagion. The nearer a person has 
been to the patient the more likely is he to convey the disease to a 
third person. Articles of clothing may retain the infection for months. 
Scales from the skin of the patient, dried secretions, the urine if 
nephritis exists, and faeces are also mediums of infection. The longer 
the physician remains near the patient the more likely is he to convey 
the disease. This mode of infection occurs. Osier records his 
belief in having carried infection to a patient. Foodstuffs handled 
by those suffering from the disease or by those who have been near 
patients may convey the disease. This is especially the case with 
milk, which is said to have been the cause of epidemics in England. 
The poison of scarlet fever seems to pervade the ward or sick-room 
for a long time. Whether this period extends over two years, as 
recorded by Murchison, is a matter not yet settled. We do not yet 
know how the poison obtains entrance to the body. The discharge 
from a scarlatinal otitis is said to be capable of communicating 
the disease. 

Susceptibility. — All children exposed to infection do not con- 
tract the disease. It is less contagious than measles. On the 
other hand, although a person may be exposed once and escape, he 
is not necessarily immune to future exposures. A nurse attended 
many cases for me before contracting the disease. As a rule, one 
attack of scarlet fever protects a person from subsequent attacks. 
The literature records cases of well-observed second and third 
attacks. The author has met cases of a second attack. We should, 
however, be cautious in accepting rejiorts of repeated attacks. 
Rotheln may have been mistaken for scarlet fever. 

Occurrence. — Scarlet fever occurs at any age, and in all coun- 
tries, being endemic in North America and Europe. It is most 
prevalent in autumn and winter (September to February). It 
remains endemic wherever introduced. Sporadic cases occur. It 
occurs also in epidemics. In epidemics only 38 per cent, of the 
population are affected. There is therefore an immunity of the 
majority (Jiirgensen, on the Faroe Epidemics). As a rule, fully 56 
per cent, of those exposed before the twentieth year contract the 
disease. 

Incubation. — According to the German authorities, scarlet fever 
has an incubation period of from eight to eleven days. Eng- 
lish authors (Murchison) fix the period at from three to six days. 
The vast majority of cases develop within a period of from three 
to five days after exposure. If eleven days elapse without the 
appearance of symptoms, we may with reasonable certainty say that 



SCARLET FEVER. 233 

the danger is past. Cases of thirty days' incubation are recorded, 
and the author had a case in his practice in which a physician con- 
veyed the disease, the boy being attacked three weeks after his visit. 
In all such prolonged periods of incubation, however, there is a 
probability of a more recent exposure. The contagion is active dur- 
ing the period of incubation and during the eruptive and desquama- 
tive stages. The consensus of opinion is that the contagion dimin- 
ishes in the desquamative stage. We should exercise great caution 
in allowing convalescents to communicate with the healthy. Strange 
to say, there are no positive data on this point. Contagion will be 
treated more fully under Prophylaxis. 

Immunity. — Although there is no absolute immunity at any 
age, scarlet fever attacks nursing infants less frequently than older 
children. We have no positive data as to transmission of the affec- 
tion in utero. Cases are recorded in which the newly born infant 
has been attacked, but some authors are inclined to look on such 
cases with doubt. In certain sets of cases the affection takes on a 
virulent form — cases in families in which all the members attacked 
will have complications, septic or otherwise, of a fatal character. 
An instance came under the author's notice in which during a very 
ordinary epidemic of scarlet fever one family lost two of three 
children attacked. All had septic malignant fever. There may in 
such cases be an element of mixed infection (Henoch). 

Symptomatology. — Scarlet fever does not present uniform 
symptoms. A general description of the disease can hardly be 
given without misleading the student. During an epidemic or dur- 
ing the prevalence of scarlet fever, there are a number of cases of 
angina in which no exanthema of scarlet fever is seen. This is 
especially so with those whose duties keep them near scarlet fever 
patients. There is no doubt that such anginal cases are capable 
of conveying the disease to others. A case of this kind has come 
under the author's notice. A nurse suffering from an angina went 
from a scarlet fever case to a healthy child. Although the nurse had 
taken all external precautions she conveyed the disease to the child. 
This raises the question of scarlet fever sine exanthema. Let us 
say that scarlet fever poison can cause a specific angina capable of 
conveying the disease to the healthy. Certain forms of exanthema 
of scarlet fever are very evanescent, and in anginal cases may 
escape observation. 

The period of incubation has no fixed symptomatology. In 
many cases the symptoms begin with the appearance of the eruption. 
The children play about ; they have a slight angina, but do not 
complain. This is apt to be the case with children who are suf- 
ferers from chronic catarrh, enlarged tonsils, or adenoids. In other 
cases the invasion of the disease is a stormy one. There may be an 
initial convulsion preceded by a sharp rise in temperature. Exami- 



234 



THE SPECIFIC INFECTIOUS DISEASES. 



nation in such cases may show, previous to the appearance of the 
eruption, a marked angina or a membranous deposit on the tonsils, 
but nothing more. Other children suffer from a tonsillitis of mod- 
erate severity, a marked febrile movement, and, what is character- 
istic, attacks of anorexia and vomiting. A chill, followed by fever 
and vomiting, ushers in a large number of scarlatinal anginas. 
Occasionally the symptoms of invasion are so mild and evanescent 
as to escape the notice of even watchful parents. These are the 
cases in which the first symptom to attract attention belongs to a 
later period of the disease or to some of the complications. There 
are thus all degrees in the severity of the symptoms of the period 
of invasion, varying with the susceptibility of the subject and the 
virulence of the epidemic. 

General Course of the Disease. — An attack of scarlet fever 
takes a certain general course. After the initial symptoms described, 

Fig. 29. 



1 2 



106" 
105' 

104' 

'-:. 103' 

cr 

I 

m 101° 

H 

100° 








i 



m 



U 



m 



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Moderately severe scarlet fever ; female child four years of age. Normal course. Observed 

from the outset. 



twelve to thirty-six hours elapse, when an eruption or rash appears 
on the skin : this eruption, though characteristic, varies greatly in 
intensity, mode of spreading, and distribution. The fever is now 
very high ; the eruption spreads and becomes more intense and gen- 
eral (Fig. 29). At the greatest intensity of the eruption or flores- 
cence the fever is highest. In typical cases of scarlet fever the 
eruption reaches its full development and runs its course within 
two to six days. At the end of this time it fades, and desquama- 
tion begins. The fever subsides gradually, leaving the patient con- 
valescent. The period of invasion is not so sharply defined as in 
measles, nor is the stage of eruption so distinct and uniform as in 
that disease. The length of the period of desquamation in both 
measles and scarlet fever varies. 



SCARLET FEVER. 



235 



The malignant cases may at first appear mild. The children are 
taken with vomiting and a moderately high fever, and the eruption 
appears. While the eruption is spreading, however, the patients 
become stupid, and within a few hours after the appearance of the 
exanthema pass into a state of coma. The urine is diminished in 
quantity or suppressed, and contains blood, albumin, and casts. 
The temperature remains elevated (Fig. 30). The pulse is rapid 
and at times thready. These patients remain comatose and die 
within a few days (three or four) of the onset of the symptoms. In 
other malignant cases the affection of the throat and adjacent lymph- 
nodes is a leading factor in the septic phenomena, while the kidneys 
show very little participation in the general toxaemia. Such patients 
will show necrotic pseudomembranous inflammation in the fauces 
after the eruption is fully developed. The glands of the neck are 



Fig. 30. 


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Malignant scarlet fever; ursemic symptoms from outset. Boy, six years. Sopor increas- 
ing to coma ; bloody urine. Involuntary passage of urine and feces. Death in three days 
after onset of symptoms. 



involved. The temperature ranges from 103° to 105° F. (39.4° 
to 40.5° C), with daily remissions. The patients have a sallow, 
septic appearance, and are stupid and irritable. The exanthema fades 
slightly after having been in efflorescence. The lymph-nodes in the 
neck enlarge to great size. These patients may die in the second 
week from general toxaemia. Between the normal course and these 
malignant forms there are all degrees of severity and mildness in 
this affection. 

We shall now consider the various phenomena of the disease. 

The Angina. — The angina of scarlet fever is limited to the pillars 
of the fauces, the uvula, the tonsils, and retropharynx. With this 
there may be a slight suffusion of the eyes. The angina may be 
simply a slight redness of the fauces and very slight swelling of 
both tonsils. The lymph-nodes at the angle of the jaw may be 



236 THE SPECIFIC INFECTIOUS DISEASES. 

very slightly enlarged. The tonsils may be so greatly enlarged as 
to close the opening of the fauces. This is likely to be the case if 
there has been antecedent hypertrophy of the tonsils. No mem- 
branous deposit may be seen, yet there may be a distinct lacunar 
form of tonsillitis. The lymph-nodes at the angle of the jaw may 
be much larger than in the milder anginal cases. The swelling of 
the lymph-nodes may involve the connective tissue about them in a 
phlegmonous mass. This is especially so in the severe septic forms 
of scarlatinal angina of the streptococcus variety. 

Membranous Angina. — Membrane spreading to the pillars of 
the fauces may be present on one or both tonsils. This condition 
was formerly called scarlatinal diphtheria. In the vast number of 
cases of scarlet fever — in fact, in all the uncomplicated cases — this 
membrane is not a true diphtheria like the diphtheria of Loffler. 
It is a streptococcus membrane (diphtheroid), caused by the strepto- 
coccus of pseudomembranous formations. This membrane may 
involve the posterior pharynx and nares, and spread downward into 
the larynx and trachea. True diphtheria of Loffler occurs in those 
cases of scarlet fever which have been exposed to the infection of 
diphtheria at or about the time of the outbreak of the scarlet fever 
or at some period during the course of the disease. The membrane 
in these cases will show, on examination, the Bacillus diphtheriae 
of Loffler. These cases of true diphtheria complicating scarlet fever 
are exceptional, and presuppose an exposure both to diphtheria and 
scarlet fever. The pseudodiphtheria is usually caused by a strepto- 
coccus of the scarlatinous variety. In some forms of scarlet fever 
this pseudomembranous inflammation of the tonsils becomes a pri- 
mary factor in the disease at an early period before the full devel- 
opment of the eruption. This process involves the lymph-nodes 
and the whole connective tissue of the neck below the jaw in a 
necrotic streptococcus inflammation. In many cases a true strep- 
tococcsemia may result from the entrance of the streptococci into 
the circulation. In other cases the patient may have passed through 
the eruptive stage and the process originating in the tonsils may 
play a leading role in the disease. Retropharyngeal abscess, medi- 
astinal burrowing abscess, abscess pointing on the external portion 
of the neck, or empyema, may result from the necrotic tonsillar 
affection by extension through the lymph-nodes. Secondarily, a gen- 
eral systemic infection may result in such cases. 

The mucous membrane of the mouth presents nothing character- 
istic in the great majority of cases of scarlet fever. The buccal 
mucous membrane is pale, and of a normal hue at first ; the soft 
palate may present a few red, irregularly shaped spots or red 
streaked areas, or these may be absent. Later in the course of the 
disease a stomatitis may appear. This is more likely to occur in 
the so-called septic cases. In these the superficial epithelium is 



SCARLET FEVEE. 237 

removed ; the mucous membrane has a dry, red, beefy appearance. 
The lips are fissured and bleed easily. 

The tongue in most cases of scarlet fever is furred at the outset, 
and may present a slightly reddened appearance at the borders and 
tip. Only occasionally do we find the so-called characteristic straw- 
berry tongue. This shows an undue prominence and erection of the 
papillae of the tongue, especially at the tip. The tip is red, and 
with the prominent papillae gives the appearance of a strawberry or 
of the tongue of the lower animals (cat). In many cases the tongue 
later becomes denuded of epithelium and shows the erected papillae 
on the dorsum ; in others it becomes dry and fissured. The latter 
condition is seen in the fatal toxic cases. 

The Exanthema. — The exanthema of scarlet fever, though very 
characteristic in appearance, varies more than in any of the other 
exanthemata in mode of appearance, distribution, spreading, and 
in duration. In the mild cases the eruption is sometimes so 
evanescent as to escape notice. In other cases it appears only 
on certain parts of the surface. It may be very discrete in 
form and punctate. Usually it first appears on the upper part 
of the chest about the clavicles, spreads down the chest, and 
around upon the back. At this time it is also seen on the 
neck, beneath the jaw, behind the ears, and on the temples. 
It consists of a very finely punctate rose-colored rash. The 
punctate appearance is the distinguishing feature of the eruption. 
At the outset this punctate character is best observed on the chest, 
abdomen, and the nates. If the eruption has in places become 
confluent, the skin shows a uniform redness. In such cases the 
punctate character of the rash can best be discovered by studying 
the skin from a distance in bright daylight. It will then be made 
out distinctly in those places in which the rash is most recent. A 
favorite method is to completely undress the patient and study the 
lower abdomen, the thighs, and nates. In the early cases the 
punctate character of the rash is apparent on the neck and behind 
the ears. The appearance of the face at the outset of the dis- 
ease is characteristic. There is a pallor about the mouth and 
alae nasi, while the cheeks are flushed with a flame-like ery- 
thema. The cheeks do not show the characteristic punctate rash, 
although flushed either from the fever or intense dermatitis, which 
involves the whole surface. The eruption spreads from above down- 
ward, involving the arms and forearms, hands, and lower extremities. 
It retains the punctate character wherever it spreads, but loses this 
characteristic after it has been out for a short time and become con- 
fluent. When confluent the rash causes the skin to appear uniformly 
red and swollen. The skin is roughened in patches by the erection 
of the papillae. In other cases, and especially in those occurring in 
summer, the skin is studded with myriads of minute vesicles. In 



238 THE SPECIFIC INFECTIOUS DISEASES. 

other cases the skin may present minute pustules. There is pruritus 
in the cases in which the dermatitis is severe. The rash of scarlet 
fever attains its full development at the end of two or three days. 
It is then said to be in efflorescence. It remains out a variable 
length of time, in some cases six days. In other cases the eruption 
may develop fully in two days and then fade. Cases in which the 
rash is visible for only twenty-four hours are not uncommon. The 
appearance of a fading scarlet fever rash is very characteristic if it 
has involved the whole surface. The skin is dotted here and there 
by raised papillae, and appears as if irregularly and lightly daubed 
with rouge. Even a fading rash may be easily diagnosed by an 
experienced observer. In mild cases the rash may disappear within 
twelve hours, leaving no vestige of its presence. In other cases the 
rash appears only on the lower part of the abdomen and upper part 
of the thighs. 

The eruption on the lower part of the extensor surface of the 
forearms, and also on that of the legs, is apt to assume a blotchy, 
roseola-like appearance. Such cases have been mistaken for measles. 

Abscesses or furuncles, multiple or single, may involve the skin. 
In rare cases gangrenous processes have been recorded. A secondary 
infection may be assumed in all of these cases. 

The Fever. — In the first few hours there is a rapid rise of 
the temperature to 104° or 105.8° F. (40° or 41° C.) It 
remains high with morning remissions until the eruption on the 
surface reaches its full development. With the fading of the erup- 
tion the temperature falls, and within six days, if the case is uncom- 
plicated and typical, becomes subnormal. The patient may show a 
subnormal temperature for a few days, after which it may rise to the 
normal. In some cases the temperature may rise very rapidly, 
reaching its highest point within a few hours. It may then fall to 
the normal rapidly, though the eruption be still present. Wunder- 
lich and Henoch record cases of profuse exanthema with a mild 
febrile course or practically afebrile curve, 101.1° F. (38.4° C), 
falling rapidly to 100.4° F. (38° C.) within twenty-four hours. 
In those cases in which there are complications either in the throat, 
ear, joints (rheumatism), or serous cavities, the temperature-curve 
will be influenced accordingly. In other cases, evening remissions 
may occur instead of morning ones. After the fading of the erup- 
tion the fever may continue for days, 100.4° to 102.2° F. (38° to 
39° C), in the absence of any complication. After days or weeks 
of absence of temperature there may occur a distinct rise and 
a species of relapse similar to that seen in typhoid fever. This 
is probably due to a form of secondary streptococcus infection. 
During the height of the eruption the temperature may reach 107° F. 
(41.6° C), although in mild cases it may not be over 103° F. 
(39,4° C). In cases of septic infection, especially of the lymph- 



SCARLET FEVER. 



239 



nodes, or in streptococcus diphtheria, with infection of the lymph- 
nodes, the temperature-curve will be of a remittent character, fall- 
ing and rising once or twice in twenty-four hours, and may retain 
this character throughout the aifection. Uraemia or any affection of 
the pleura, lungs, or heart will be ushered in by a rise of temperature 
even if it has returned to the normal. If a complication occurs early 
in the disease, the temperature will fail to drop to normal with the 
fading of the eruption (Fig. 31). In cases of otitis persisting 
through the stage of desquamation there will sometimes be an 
evening rise, although the ears are discharging freely. In such 
cases the bone may be involved (mastoid disease). In severe, malig- 
nant forms in which symptoms of profound sepsis, such as coma or 
stupor, are present from the outset, the temperature remains persist- 
ently high (105.6° F., 40.8° C), remitting a degree toward morn- 
ing. The temperature remains high until the fatal issue (see Fig. 30). 





















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Scarlet fever, moderate severity, in a boy six years of age. Shows the delay in the drop 
of the temperature due to complic?ating otitis of the right ear at the outset of the period of 
desquamation. 



Desquamation. — The period of desquamation begins as soon as the 
exanthema commences to fade. Generally speaking, since the 
exanthema first appears on the upper part of the chest and neck 
we should expect desquamation to begin there. It may be in fine, 
branny scales, such as are seen in measles; or else, as is most com- 
mon, the skin peels in larger particles. The hands and feet show the 
largest scales, and complete casts of the hands and feet are some- 
times shed. I have seen the nails shed completely twelve weeks 
after the attack. The desquamation may be scarcely perceptible. 
In some cases only certain parts of the extremities, such as the toes 
or inner portion of the thighs, show desquamation. It is, however, 
always present. Desquamation in itself is not a pathognomonic 
symptom of scarlet fever. It occurs in forms of dermatitis which 
bear no relationship to the disease. It is still a subject of debate 
whether cases of angina without an exanthema may desquamate. 
Henoch is inclined to think this possible. We should remember 



240 



THE SPECIFIC INFECTIOUS DISEASES. 



that an evanescent, slightly marked exanthema may escape the notice 
of even the most careful observer. 

The duration of desquamation is variable. I have seen the skin 
desquamate a second time. The severity of desquamation has no 
relation to the intensity of the exanthema. Some very marked cases 
of scarlatina desquamate less than those in which the eruption has 
been faintly marked. 

The Nose. — The close relationship of the nasal passages to the 
pharynx facilitates the invasion of bacteria from the throat. The 
nasal passages become affected simultaneously with the severe angina. 
There is a severe catarrhal or pseudomembranous inflammation of 
the mucous membrane. In the so-called septic cases there may be 
an ichorous discharge from the nostrils. There will be in such cases 
erosions, and sometimes fetor, with the discharge of necrotic tissue 
through the nasal passages. Necrosis of the cartilaginous and bony 
structures may result. In other forms there is a pseudomembranous 
deposit around the opening of the nostrils extending up into the 
nasal passages. Casts of the nasal passages may be expelled. The 
membrane may leave a bleeding surface. 

Ear. — Duel found the ears affected in 20 per cent, of the cases 
of scarlet fever. Generally both ears are diseased. Deafness 

Fig. 32. 




Female child, two and a half years of a^e. A mild form of scarlet fever complicated in the 

second week by an otitis. 



is frequently a result of otitis. Ten per cent, of those who suffer from 
deaf-mutism can trace their affliction to scarlet fever. Usually the 
ears become affected in the third week, although they may be in- 
volved at the outset of desquamation. The affection of the ears is 
ushered in by a rise of temperature and manifestations of pain (Fig. 
31). Occasionally tinnitus and deafness are initial symptoms. 
There may be convulsions or even cerebral symptoms. The onset 
of ear trouble may be insidious, and not suspected until the purulent 
discharge makes its appearance. If there are premonitory symp- 
toms, they may precede the perforation by one to three days. Ear 



SCARLET FEVER. 241 

complications in scarlet fever are always of serious moment. Men- 
ingitis, sinus thrombosis, and abscess of the brain are among the 
more serious results, and may result long after the fever has run its 
course. The onset of otitis usually occurs during the period of 
desquamation. The patient may be up and about. There is still 
some redness of the throat, with swelling of the lymph-nodes. There 
is a sudden rise of temperature to 103° or 104° F. (39.4° or 40° 
C). The child begins to vomit food and has headache. At night 
the child starts from sleep and cries as if in pain. Children do not 
always locate the pain in the ear. The reason is that the pain occurs 
before the child is quite awake. The sleep is restless. The muscles 
of the face and hands twitch in sleep. These symptoms may at 
times abate. The temperature may fall to the normal and then rise 
sharply. Any of these symptoms should direct attention to the ear. 

The mastoid may become the seat of inflammation in the fifth or 
sixth week. The ears may have been discharging very freely. The 
child is not, however, free from fever. At times during the day 
the patient complains of frontal headache, is drowsy, and the tem- 
perature shows a rise to 102° or 103° F. (38.5° or 39.9° C). 
There is tenderness behind the ear or in front of the auditory 
meatus. There may be a slight blush above and behind the pinna. 
In these cases the mastoid may be the seat of suppuration. There 
are forms of otitis which occur on the eighth day of the disease. The 
temperature does not fall to the normal. The patient has begun to 
desquamate, but the temperature remains elevated a degree or more 
and takes fully three or four days longer to fall to 99° F. (37.2° 
C.) in the rectum than in an uncomplicated case. At the eleventh 
day of the disease pain is complained of. The drumhead is found 
to be bulging. An insidious serous otitis media is in progress. 

The Eye. — Conjunctivitis may appear in some cases of scarlet 
fever as a result of a mixed infection. The lachrymal duct is the 
canal through which such infection travels. Conjunctivitis in cases 
of gangrenous pharyngitis and rhinitis may lead to panophthalmitis 
and destruction of the bulb. 

Lymph-nodes. — The lymph-nodes in various parts of the body 
enlarge in scarlet fever. Those situated at the back of the neck 
behind the posterior border of the sternomastoid muscle may enlarge 
some days before the appearance of the exanthema. At the time of 
the eruption we may find the lymph-nodes in the axilla, inguinal 
region, and those at the angle of the jaw, enlarged. In other cases 
the lymph-nodes, except those at the angle of the jaw, may not be 
perceptibly enlarged. In some cases the lymph-nodes at the angle 
of the jaw may enlarge at the end of the second week, with a dis- 
tinct rise of temperature to 104° F. (40° C.) or more, as a result of 
reinfection through the tonsils and pharynx. The connective tissue 
of the neck beneath the body of the jaw is involved in the inflamma- 

16 



242 



THE SPECIFIC INFECTIOUS DISEASES. 



tion of the nodes. In such cases the swelling has an appearance similar 
to that seen in angina Ludovici. In severe mixed infection the tissues 
of the neck may become gangrenous. As a result of such severe 
gangrenous inflammation, phlebitis erosion into the veins and arteries 
with fatal hemorrhage may result. Retropharyngeal abscess or retro- 
pharyngeal adenitis is a sequence of infection of the lymph-nodes. 
The retropharyngeal abscess in such cases is not as benign as that 
occurring independently of scarlet fever. In the latter the abscess 
is apt to involve a chain of retropharyngeal nodes. Multiple bur- 
rowing abscesses result. The nodes of the mediastinum may be 
affected, causing empyema or pericarditis. The mediastinal abscess 
may cause death by pressure on the trachea, or, by eroding the 
trachea, burst into it and cause death through suffocation. 

The Mouth. — Stomatitis always occurs in severe scarlet fever. It 
may be simply a mild catarrhal process. If there is a pseudo- 
membranous formation on the tonsils, this pseudomembrane may 
spread to the mucous membrane of the soft palate, and the buccal 
mucous membrane may also become affected. The tongue is dry 
and fissured ; the lips are dry, fissured, and bleed easily. There 
may be a discharge of necrotic tissue from the mouth. The soft 
palate, tonsils, and pharynx may be fused into a necrotic mass, emit- 
ting an offensive odor. 

Joints. — The joints become inflamed in from 2 to 6 per cent, of 
the cases of scarlet fever. This aflection of the joints has been called 

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Boy five years of age, observed from the outset of the disease. Scarlet fever with joint-com- 
plications. No cardiac involvement. Recovery. 

scarlatinal rheumatism. The joint-affection may, in exceptional 
cases, precede the exanthema. It appears, as a rule, in the second 
or third week of the disease (Fig. 33), and is therefore one of the 
manifestations seen during desquamation. There may be pain in 
several articulations. In other cases SAvelling may occur, with effu- 
sion of serum into the joints. These cases retrograde. There may 
be a complicating endocarditis. In other cases there is suppuration 
of the joint. Aii arthritis with streptococci in the joint-effusion 
results. The streptococci invade the joint through the epiphyses of 
the bone, and produce a streptococcus osteomyelitis with suppuration 
of the adjacent joints (Lannelongue, Achard, Koplik, Van Arsdale). 



SCARLET FEVER. 243 

As a rule, suppuration occurs in only one joint. Cases in which 
several joints are aiFected are generally septic, streptococci having 
gained access to the general circulation through a necrotic focus in 
the throat or pharynx. Such cases are fatal. There are metastases 
in the lungs, kidneys, pleura, and pericardium, with hemorrhages in 
the skin and enlargement of the spleen. Periarticular abscesses rarely 
occur (Henoch). The prognosis is serious in all suppurative cases. 

The Kidneys. — In scarlet fever, as in most infectious diseases, 
there may be a mild form of nephritis in the earlier stages. There 
are a small amount of albumin and a few hyaline casts in the urine. 
This nephritis is of little significance, and has nothing in common 
with the severer form which occurs later in the disease. The severe 
form of nephritis begins as a rule in the third week. It has been 
known to appear in the sixth week. The frequency of this compli- 
cation varies in different epidemics. In some, only a small number 
of cases are affected (5 per cent.). In other epidemics fully 70 per 
cent, of the cases are thus complicated. Its occurrence cannot 
always be predicted from the severity of the disease. The mildest 
cases may develop severe nephritis. The diphtheritic forms of 
angina are more likely to be complicated with or followed by 
nephritis. On the other hand, the severest forms of scarlet fever 
may run their course without marked nephritis. Sorensen has 
shown that at autopsy the most marked changes may be found in 
the kidneys, although no clinical signs of the affection have been 
manifested during life. In 50 per cent, of the autopsies upon scarlet 
fever patients Friedlander found changes in the kidneys. It was 
formerly thought that exposure played an etiological role in this affec- 
tion, but this view has been abandoned. Nephritis may develop in 
cases which have been very carefully guarded from exposure from 
the outset. Although the symptoms will be detailed elsewhere, it 
may be here stated that the first symptom is a slight oedema about the 
eyes and face which spreads to the rest of the body, involving the 
trunk and extremities, the hands and dorsum of the feet, and the 
scrotum. In some cases the oedema is not marked, in others the 
anasarca is extreme. The serous cavities may become the seat of 
effusion, and there may be hydrothorax, hydropericardium, or ascites. 
The urine also shows changes very early. The quantity diminishes 
very rapidly, or it may be completely suppressed. The urine shows 
the presence of albumin, rarely more than 0.5 per cent. It may be 
highly colored or smoky, or may be distinctly red in color, owing 
to the large amount of blood and blood-pigment contained. The 
urine in cases of partial or complete suppression generally contains 
a large amount of albumin, blood, hyaline, epithelium, and blood- 
casts, renal epithelium, and leucocytes. The specific gravity may 
at first be high, 1.030 ; later, when diuresis is inaugurated, it may 
fall to 1.006. All cases do not run their course with anasarca. 



244 THE SPECIFIC INFECTIOUS DISEASES. 

Henoch has seen cases without this symptom. The invasion of the 
affection is sometimes marked either by a rise of temperature or 
convulsions. The prognosis is good in spite of the very alarming 
symptoms, such as convulsions and coma, which are seen in some 
cases. This nephritis usually runs its course in from four to six 
weeks, leaving the kidneys intact. Sometimes the nephritis appar- 
ently subsides, but albuminuria of a very mild or intermittent form 
persists for months. In fact, many of the so-called cases of par- 
oxysmal albuminuria are probably due to unnoticed scarlatinal 
nephritis. Finally, the author has seen cases in which the anasarca 
recurred at long intervals as a result of chronic diffuse nephritis. 

Uraemia. — Uraemia commonly sets in with a diminution in the 
whole quantity of urine passed daily. It may supervene without 
any distinct change in the quantity or quality of the urinary excre- 
tion (Henoch). In these cases the changes in the urine follow the 
appearance of the ursemic symptoms. Uraemia may also appear 
notwithstanding the passage of an increased amount of urine. The 
latter mode of onset in uraemia is very uncommon. The early 
symptoms are vomiting, headache, and slight twitching of the facial 
muscles. These may subside with the abatement of the nephritis. 
We may have, however, eclampsia as the first symptom, with tonic 
or clonic convulsions, unconsciousness, and coma with temporary 
absence of the reflexes. The respirations are increased, and in most 
cases the temperature rises. The pulse is small and the skin dry. 
The convulsions may subside, but the coma may continue. The 
eclamptic seizures may be repeated. The uraemia may subside, and 
after a very protracted interval reappear with a repetition of the 
above phenomena. Mania, melancholia, and aphasia may ensue. 

Amaurosis without changes in the retina is a more common con- 
dition. The retinitis of Bright' s disease is absent in scarlet fever. 
Litten found a swollen condition of the papilla. Amaurosis may 
persist in the intervals between the convulsions. 

The heart action immediately preceding the convulsions is slow. 
The pulse may be as low as 40 per minute. During the convulsions 
the heart action is increased. The respirations may be 60 and the 
pulse 200 (Jiirgensen). 

The temperature may be 100.4°-103° F. (38°-39.5° C), rarely 
107.6° F. (42^ C), with an initial chill (Jiirgensen). 

Uraemia may set in at any time while the kidney is affected. 

The Heart. — Myocarditis of an acute infectious character is likely 
to supervene in septic cases of scarlet fever. The changes in the 
myocardium may also be secondary to changes in the pericardium 
and endocardium. 

Endocarditis of the cardiac walls is more frequent than that of 
the valves. For this reason murmurs should be carefully observed. 



SCARLET FEVER. 245 

No conclusions as to their valvular origin can be reached until long 
after convalescence. Endocarditis is uncommon, but is more fre- 
quent in this disease than in diphtheria or typhoid fever. 

Pericarditis is rare. Muscle murmur is often mistaken for it. 
If present, pericarditis is usually of the dry fibrinous or serofibrinous 
variety. It is rarely purulent, except in cases of marked purulent 
involvement of other organs and cavities, notably the pleura. 

Dilatation of an acute' character may supervene early in severe 
cases. In such cases we may have tachycardia or bradycardia. 
There may be cyanosis. Sudden death is very rare in scarlet fever. 

Friedlander has shown that in scarlet fever with marked neph- 
ritis and uraemia, the consequent increased arterial tension results in 
dilatation of the left ventricle, with slight hypertrophy. The weight 
of the heart is increased 40 per cent. The pulse may be slow and 
irregular. As the nephritis subsides the tension diminishes and the 
frequency of the pulse increases. Hypertrophy being the result 
of long-continued increased tension, can be demonstrated only in 
extreme cases. Dilatation is rarely so great as to cause death. 

Lungs. — The lungs may be affected by pneumonia, which is gen- 
erally of the bronchopneumonic type. Lobar pneumonia as a com- 
plication of scarlet fever is rare. Gangrene of the lung may occur 
in the severe septic cases. 

Pleura. — Pleuritis as a complication of scarlet fever usually 
appears in the middle of the second week. It is commonly of the 
serous variety, but the author has had many cases in which there was 
an empyema usually of the streptococcic variety. Fiirbringer 
has shown that in 5 per cent, of the cases of pleurisy there is neph- 
ritis. 

The Blood. — There is a diminution of the haemoglobin, which is 
marked in cases in which nephritis is present. During convales- 
cence the haemoglobin increases. Slight leukocytosis is also present 
in the course of the disease. There may be purpura and surface 
hemorrhages. 

Stomach and Intestine. — Vomiting has been mentioned as an 
early symptom in scarlet fever. It is sometimes repeated in the 
course of the disease if a cough due to any laryngeal or pulmonary 
complication exists. Diarrhoea is sometimes a serious complication. 
There may be a simple diarrhoea, in which an excessive number of 
movements may threaten the life of the patient early in the disease ; 
or, on the other hand, the diarrhoea may subside without serious 
results. The diarrhoea may take on a dysenteric or typhoidal type, 
with severe hemorrhages from the gut. There are some forms of 
diphtheria of the pharynx, stomach, and large intestine in the septic 
types of scarlet fever which have been described by Litten. 

Sequelae. — As sequelae to scarlet fever may be mentioned : 

Anaemia, which may persist for some time. 



246 THE SPECIFIC INFECTIOUS DISEASES. 

Glandular Swellings. — The lymph-nodes at the angle of the jaw 
are apt to remain enlarged long after convalescence. The tonsils 
may remain large. 

Tuberculosis may follow scarlet fever. It cannot be said that 
there is any distinct connection between the two diseases. Scarlet 
fever may leave the patient more susceptible to infection either of 
acute miliary or chronic tuberculosis. 

Nervous Diseases. — Chorea has been noted by Gerhardt to follow 
scarlet fever, as have also rheumatic joint-affections with endocar- 
ditis. 

Facial paralysis may occur as the result of prolonged otitis. 

Psychoses, such as melancholia and mania, have been noted, 
similar to those following typhoid fever or pneumonia. 

Otitis may remain with a permanent discharge and consequent 
deafness or mutism. 

The diagnosis of scarlet fever in most cases presents few diffi- 
culties ; but, on the other hand, there is no disease in which the 
symptoms are more indefinite at times. This is particularly the 
case with those patients who present an evanescent or partial exan- 
thema and only slight febrile disturbance. In some cases the diag- 
nosis must always remain in doubt. Under these conditions it is 
better to err on the safe side, and to take all precautions of isolation. 
The exanthema if partial or not very well marked is likely to be 
overlooked. The angina, which is the most constant symptom, may 
be mild. The temperature presents nothing typical as in typhoid 
fever. 

It is good practice in the presence of a localized exanthema of a 
punctate character on the thighs or lower abdomen or the upper part 
of the chest, with angina and a slight febrile movement, to consider 
the case as one of scarlet fever. In all cases of sore throat it is 
wise not to omit an inspection of the general surface. Although 
some authors have described the angina of scarlet fever as typical 
in color, the author has never found this sign of value. In some 
cases of scarlatinal angina the throat is intensely red ; in other 
cases it is of a pale-pink hue ; in still others the throat is only 
slightly inflamed. 

The enanthema is not of any service in making a diagnosis. The 
eruption on the soft and on the hard palate is not characteristic. 

Albumin in the urine is thought by some to be diagnostic of 
scarlet fever. There may be marked and unmistakable symptoms 
pf scarlet fever without albuminuria. A simple lacunar amygdalitis 
may cause it. 

We must differentiate the eruption of scarlet fever from that of 
measles and rotheln, from drug eruptions, and those due to irritants. 

Measles.— In some forms of scarlet fever the eruption on the 
forearms has a blotchy appearance. Near the wrist-joint the author 



SCARLET FEVER. 247 

has seen it closely resemble the eruption of measles. In these cases 
the punctate character of the eruption elsewhere on the surface, and 
the presence of angina, will assist us, in the absence of any enan- 
thema on the buccal mucous membrane, in coming to a conclusion. 
In measles the diffuse localization of the exanthema on the face, the 
conjunctivitis and bronchitis, will aid us. In scarlet fever parts of 
the face, such as the alse nasi and the region of the mouth, are free 
from eruption, while in measles these localities are affected by the 
exanthema. 

Rotheln. — Scarlet fever is most frequently mistaken for rdtheln, 
and vice versa. 

In rotheln, when the eruption is punctate, it is invariably dis- 
crete. There is never the severe dermatitis with swelling of the 
skin found in scarlet fever. In rotheln the lymph-nodes are more 
constantly and generally swollen behind the sterno-mastoid, in the 
axillae and groin. The throat is but slightly reddened. Rotheln 
presents a normal temperature or at the most a temperature at the 
outset of the eruption of 101°-102° F. (38.3°-38.8° C.) or even 
103° F. (39.4° C.), which rapidly subsides to the normal, although 
the exanthema may be spreading. 

Drug Eruptions. — Following the administration of quinine some 
children, like some adults, develop an eruption which closely re- 
sembles that of scarlet fever. In the presence of an angina and 
fever it may be difficult to exclude scarlet fever. Antitoxin of 
diphtheria, antipyrin, and belladonna also cause a rash closely re- 
sembling that of scarlet fever. It is well in such cases to discontinue 
the drug, and after a few days, the eruption having disappeared, to 
administer it again. If the patient be susceptible, there will be a 
repetition of skin symptoms. Kerosene rubbed on the surface will 
cause a punctate eruption the exact counterpart of a scarlet fever 
eruption. Among the poorer classes, with whom petroleum is popu- 
lar as a general remedy, we should think of the possibility of its 
having been used. If that has been the case, the skin will have a 
distinct odor of kerosene. 

Prognosis. — The prognosis in scarlet fever depends largely on 
the character of the epidemic and the prevalent type of the disease. 
In some epidemics in New York City the mortality has been exceed- 
ingly low — 2 to 4 per cent. (J. L. Smith), while in others it has 
been notably high. In England the mortality varies from 13 to 40 
per cent. 

Personal idiosyncrasy will affect the prognosis. Some children 
develop malignant septic types of the disease although the prevailing 
epidemic is mild. 

Cases complicated with severe angina of a septic character do 
badly from the outset. 

Nephritis is a complication greatly to be feared. It may result 



248 THE SPECIFIC INFECTIOUS DISEASES. 

in uraemia and death, or the acute may be followed by a chronic 
nephritis which will ultimately prove fatal. 

Otitis may cause serious and even fatal complications, such as 
brain abscess or sinus thrombosis. 

Affections of the endocardium or pleura may prove fatal. 

The prognosis of the so-called scarlatinal rheumatism is good. 
The joints, even if synovitis develops, retrograde as a rule to 
the normal in from two to three weeks. This may result even if 
high fever persists for some time during the joint-affection. In 
the presence of joint-complications it is necessary to be on the look- 
out for endocarditis or pericarditis. The occurrence of the latter 
takes place, as a rule, in cases in which there are other signs of 
septic infection, such as pleuritis and even peritonitis. All these 
are cases of mixed infection. If synovitis is complicated with such 
a serious inflammation as pericarditis, the latter is very likely to be 
purulent, and in that case the prognosis is grave. 

We should never pronounce the patient out of danger until the 
fourth week of the disease has passed without serious complica- 
tions. A very high temperature at the outset is an element of 
danger, although not necessarily so. Septic cases with high tem- 
perature and pulse above 150 in the first week of the disease are 
always to be regarded with apprehension. 

Lotz shows that the mortality is greatest under the age of one 
year and between the first and second year. The lowest mortality 
according to statistics occurs between the tenth and the fifteenth 
year. 

Morbid Anatomy. — Skin. — The investigations of Preobrachen- 
sky show that daring the interval from the third day to the fourth 
week certain changes occur in the skin. These consist chiefly in an 
erythematous inflammation of the papillary layer, with hyperaemia, 
hemorrhages, and a diapedesis of erythrocytes and leucocytes. There 
is an oedematous infiltration of the connective tissue of the skin. The 
cells of the rete Malpighii show vacuolization. There is also an infil- 
tration of the sudoriparous and sebaceous glands with small round 
cells. The epithelium of these glands desquamates and necroses. 
At the time of the eruption streptococci are found in the skin, 
especially in the vesicles of the sudamina. 

The changes in the kidneys will be considered in the chapter on 
Diseases of the Kidney. 

Bacteriology. — The parasitic nature of scarlet fever is still a 
matter for study. Streptococci play a leading role in the disease. 
Micro-organisms have been described in the blood (Hallier, Klebs, 
Tschamer). Others have seen plasmodium-like protozoa in the blood 
(Pfeiffer, Doehle). 

Streptococci have been found in the throat membranes (Loffler), 
in the joints (Litten, Heubner, Koplik, Van, Arsdale), and in various 



SCABLET FEVER. 249 

viscera (Frankel, Freudenberg). Streptococci have also been found 
in purulent foci of the joints and pleura (Raskin), and in the kidneys, 
in cases which have succumbed to fatal nephritis (Babes). In septic 
forms of scarlet fever these streptococci exist in the circulating blood 
(Babes, Lenhartz, Feer). Streptococci have also been found in the 
cerebrospinal fluid and bone-marrow (Baginsky). Bacteriologists, 
however, are not willing to assign to these streptococci anything but 
a secondary role, because they present no features which distinguish 
them from ordinary Streptococcus pyogenes. Kurth found that some 
of the streptococci, the so-called conglomerate-forming streptococci, 
were of a virulent type. Bretonneau, Henoch, and Heubner have 
always distinguished the diphtheria of scarlet fever from true diph- 
theria. Sorensen describes the membranous formations of scarlet 
fever as milky, yellow, smeary deposits which cannot be peeled from 
the parts. The membrane seems to penetrate into the mucous sur- 
faces. Ulcers form, and the tonsils, soft palate, uvula, and naso- 
pharynx become a necrotic, sloughing mass. Scarlatinal diphtheria 
is pre-eminently an inflammatory process with high fever, swelling 
of lymph-nodes, and suppurations in diflerent parts of the body. 
If the larynx and trachea are affected, the bronchi rarely become 
involved. The contrary is true of Loffler diphtheria. In the latter 
the membrane can be peeled from the surface of the mucous mem- 
brane. The membrane is rich in fibrin, and spreads more on the 
surface and not in the depths. True diphtheria is followed by 
paralyses. A peculiarity of scarlet fever is that it may occur 
sporadically for years and yet not become epidemic. This is in con- 
trast to what occurs in measles. In the latter disease the affection 
may disappear almost completely and suddenly reappear in epidemic 
form (Henoch, Johanessen, Feer). Epidemics of scarlet fever are 
less common than those of measles. 

Treatment. — Prophylaxis. — The diagnosis of scarlet fever once 
made, the patient should be isolated from the rest of the family. 
If several children are affected in the same family, these children 
should be separated and not placed in one room. Otherwise rein- 
fection will occur. The clothes worn just prior to the illness should 
be sterilized in steam and then aired in the sun. Sufferers with 
angina who have been about the patient should not be allowed to 
come into contact with the healthy. All the children of the family 
should be kept from school. During the illness the bedclothes and 
linen of the patient should be put into a 1 : 5000 solution of mer- 
curic chloride, prior to being boiled and dried and aired in the sun. 
The sick-room must be kept well ventilated. There is no advan- 
tage in keeping the temperature of the sick-chamber too low. The 
author has found a temperature of 68° F. (20° C.) comfortable for 
the patient and those about him. Sunshine and fresh air are of 
more value than a room uncomfortably cool. If possible, it is well 



250 THE SPECIFIC INFECTIOUS DISEASES, 

to spray with some simple cleansing solution morning and evening 
the throats of any children of the family who are not affected. 

The physician should take off his coat and vest and put on a 
linen robe of some kind before entering the sick-room. On his 
departure he should leave this robe outside the sick-room, or, better 
still, outside the window of an adjacent room. If the physician 
wears a beard, he should wash his face in a 1 : 2000 solution of 
mercuric chloride after leaving the patient. The hands should also 
be scrupulously disinfected. When he returns home he should 
make a complete change of clothing before visiting other patients. 
Carpets and superfluous furniture should be removed from the sick- 
room. The hanging of sheets wet with disinfectants in the door 
of the sick-room is not essential. 

Those about the sick should have no intercourse with the 
healthy, nor should they go through the house. Meals should be 
carried by others to some neutral spot. 

After convalescence the question of the disinfection of the sick- 
room and its occupation by others arises. It nuist be confessed that 
at present we are in possession of no absolutely sure method of dis- 
infecting a room after its occupancy by a scarlet fever patient. We 
may adopt one of two methods. The cracks and spaces in the win- 
dows and doors are closed with strips of paper glued over them. 
The disinfectants, preferably a large quantity of binoxide of man- 
ganese, table salt, and sulphur, are placed in the centre of the room. 
The sulphur is then ignited and the doors sealed. Formalin is also 
effective. After twenty-four hours the room is opened and aired, 
and the floors and walls are scrubbed with 1 : 2000 corrosive subli- 
mate. In hospitals the scrubbing is suflicient. The floor and walls 
about the bed occupied by the patient are scrubbed, and also the bed. 
The mattresses are steamed in a sterilizer constructed for the pur- 
pose. In families it is best to destroy or burn all bedding of hair. 
Rugs may be aired and disinfected by steam at the establishments 
equipped for the purpose. 

How soon may a scarlet fever patient have intercourse with the 
healthy ? We have no exact data on this important point. Some 
authors advise that after the termination of desquamation the 
patient be given a bath of 1 : 10,000 corrosive sublimate, and then 
allowed to mingle with the healthy. Others (Baginsky) advise pro- 
longed isolation. It is not always practicable, nor indeed desira- 
ble, to isolate a patient for too long a period. Family considerations 
demand a return to the family circle as soon as possible. In these 
cases the course first mentioned is the most practicable. In cases 
which have exhibited a malignant septic form of the disease the 
author would advise prolonged isolation after convalescence, for the 
safety of the other children. The urine of a scarlatinal case if there 
are even mild signs of nephritis, such as albumin and casts, is 



SCARLET FEVER. 251 

believed to be infectious. A recent otitic discharge is thought to be 
capable of conveying the scarlatinal poison. 

The treatment of scarlet fever is largely symptomatic. In an 
ordinary mild case there is little to do but to regulate the diet, and 
keep the nose and throat freed from excess of secretion. The 
skin needs little care. During desquamation it is anointed once a 
day with a 1 per cent, salicylic acid or boric acid ointment. The 
urine should be examined daily, for even in the mildest cases severe 
nephritis is apt to intervene. Vigilance should not be relaxed 
until after the fourth week. The fever in simple cases needs only 
the mildest measures. We should remember that the tendency of 
the fever is to mount until the eruption is fully developed. It then 
naturally remits. Thus a temperature of 105° F. (40.5° C.) in an 
ordinary uncomplicated case may not last more than a few hours. 
In ordinary cases sponging with lukewarm water is efficacious. The 
aim is not so much to reduce the temperature as to support the 
nervous system and the heart. In private practice it is well not to 
resort at once to full baths simply because the temperature is above 
104° F. (40° C). The reverse is true with temperatures which are 
persistently high for days. In such cases the author resorts to full 
baths. The patient is placed in a bath at 100° F. (37.7° C), and 
the water cooled to 85° F. (29.4° C). With children it is well 
not to resort to lower temperatures. This is especially true in the 
asthenic forms of sepsis. The patients fail to react after the bath, 
and seem weakened by the excessive cold. The patients remain in 
the bath about five minutes, and are then taken out. In cases in 
which the temperature mounts above 105° F. (40.5° C.) we may 
employ the pack at a temperature of 70° F. (21.1° C), with much 
benefit if the reaction is good. The trunk pack may be repeated 
every one or two hours. The baths above described m^y be given 
every four hours. While the patients are in the bath reaction 
may be promoted by mild friction. Patients with scarlet fever, espe- 
cially young children, do not bear baths below 75° F. (23.8° C.) 
well. The old theory that kidney complications are caused by cold 
baths is not proved. On the contrary, in uraemia Kussmaul lays 
much weight on the beneficial eflPects of cold packs where hot baths 
produce untoward symptoms (Baruch). 

Antipyretics are of little value in scarlet fever, and should not be 
used unless there is some special contraindication against hydro- 
therapy. Antipyretics of the coal-tar series especially, weaken the 
heart in the toxaemia which accompanies scarlet fever. 

Heart. — The heart is supported in septic cases with high tem- 
perature, in the same manner as in other diseases of a toxic 
nature. Alcohol (whiskey) is not given in mild cases. In consid- 
ering its administration the kidneys should be taken into account. 
We wait until the temperature remains persistently high. At the 



252 THE SPECIFIC INFECTIOUS DISEASES. 

third or fourth day a constant temperature of 105° F. (40.5° C.) 
which refuses to abate with treatment calls for the employment of 
alcohol with other remedies. For a child of from two to five years 
half a drachm to a drachm of alcohol every three hours is a suffi- 
cient dose. Alcohol and digitalis are probably our best cardiac 
remedies. Caffeine and camphor may also be employed. Strychnine 
does not seem to do so well in cases in which there is an active 
myocarditis. 

Throat and Nose. — In inflammations of these passages we simply 
keep the parts sprayed with an alkaline solution in order to 
remove excessive secretion. In this way the patient is made com- 
fortable and the inflammation of the fauces kept within bounds. It 
is not always possible to spray the throats of the little ones. If 
there is nasal involvement, the passages may be kept clear by 
syringing with salt solution. Strong antiseptic solutions or solu- 
tions of sublimate or peroxide of hydrogen are of little use if 
not harmful. Antitoxin of diphtheria is employed if true Loffler 
diphtheria coexists. In the streptococcic or most common form 
of pseudomembranous inflammation we have no remedy which acts 
directly on the inflammation. Antistreptococcic serum has not given 
encouraging results. 

In those cases of scarlet fever in which there is great obstruc- 
tion of the nasal passages and enlargement of the tonsils, with 
spreading of diphtheritic membrane from the tonsil to the nasal 
pharynx and posterior nares, there is great difficulty in breathing. 
It is almost impossible in some cases to cleanse the nares on account 
of the accumulation of secretion and pseudomembrane. The patient 
lies in a semi-soporose state. The lymph-nodes at the angle of the 
jaw are greatly enlarged This condition of affairs may set in from 
the very onset of the disease. In these cases the problem arises of 
relieving the difficulty of breathing. Any interference in a surgical 
way with the tonsil would be dangerous to the patient at this time. 
Two courses are o])en to us : We may intube the nostrils with soft- 
rubber catheter tubing, each nostril being intubed with a piece of soft- 
rubber catheter, extending backward toward the posterior wall of 
the nasal pharynx. Nos. 10 to 12 are the most available calibres 
of tubing. The pieces of rubber tubing are secured externally 
with safety-pins, being cut close to the external nares. Through 
these tubes the posterior nasal space can be cleansed by cautiously 
allowing some salt solution to run through the rubber tubing. 
The relief in some cases is instantaneous ; in others the amount 
of secretion is so great as to block up the rubber tubing. There 
is then no other resource but to remove the tubing and to instil 
in each nostril 3 to 5 drops of a 1 : 4000 solution of adrenalin 
chloride three or four times daily. The relief from this remedy is 
very great in some cases. I have seen the breathing relieved at 



SCARLET FEVER. 253 

once. At the same time, owing to the fact that adrenalin is a car- 
diac stimulant, the patient is rather supported as well as relieved by 
this remedy. Its effect should, however, be closely watched. We 
should be very cautious in these cases not to irrigate the nostrils 
either too often or too forcibly, on account of the danger of ear 
complications, but should try every measure before resorting to 
irrigation. Nasal irrigation is carried out in a manner similar 
to that pursued in attacks of true diphtheria in the same situa- 
tion. 

Lymph-nodes. — The lymph-nodes, especially in the region of the 
angle of the jaw, are, if swollen, treated with local cold applications. 
This frequently affords much relief. Unless distinct fluctuation 
exists, we should avoid incision of the lymph-nodes of the neck. 
The author has seen these nodes incised at the beginning of the 
second Aveek in septic cases, with very unsatisfactory results. Pus 
is not found in such cases, but only foci of necrosis, which are best 
left to nature until the patient regains strength. Later in the dis- 
ease such nodes may suppurate and need incision. 

Nephritis. — The treatment of nephritis is elsewhere described in 
detail. The lines of procedure are indicated here. Headache, vomit- 
ing, and convulsions are treated with hot baths, and by the con- 
tinuous irrigation of hot saline solution (Kemp) per rectum. The 
kidneys are apt to be affected from the outset in malignant cases. 
In these cases the Kemp treatment with saline enemata is most suit- 
able. With young or intractable children the continuous irrigation 
of Kemp cannot be carried out. In these cases a high rectal enema 
of normal saline solution (Cantani) is given twice daily or more 
often if necessary. If general anasarca is present, the patient is 
given two warm baths daily ; or by wrapping him in a blanket 
which has been moistened with hot water and then wrung dry we 
may facilitate diaphoresis with hot air. Digitalis in the form of 
infusion is the most efficient remedy, combined with moderate doses 
of potassium acetate, tartrate, or citrate. Milk is the exclusive diet. 
Complete suppression of urine, with blood and all the anatomical 
elements of severe inflammation of the kidney, will sometimes be 
followed by an increased amount of urine. In such cases the treat- 
ment just indicated will not be efficacious. The heart must be sup- 
ported, and watch kept for ursemic symptoms. Opium should be 
employed with extreme caution — best not at all in convulsions ; 
chloroform inhalations with chloral per rectum are preferable. Saline 
enemata at 108° F. (42.2° C), diuretin, and nitroglycerin are appli- 
cable in those cases in which there is suppression of urine. 

Otitis is sometimes first indicated by spontaneous perforation and 
purulent discharge. In other cases pain Avith a sharp rise of tem- 
perature will indicate inflammation of one or both ears. Para- 
centesis is best performed early, even if only slight redness of the 



254 THE SPECIFIC INFECTIOUS DISEASES 

drum is present. Later in the disease (fifth or sixth week) both 
ears may continue to discharge profusely, with an evening rise of 
temperature. In some cases the author has noted slight frontal 
headache and drowsiness toward evening. There may be only a 
slight redness over the mastoid of one or both ears. It is best not 
to temporize in such cases, but to advise opening the mastoid process 
to insure drainage and avoid sinus thrombosis or cerebral abscess. 

Complications in the lung, such as bronchopneumonia, are treated 
on general lines. We should in all cases be on the lookout for 
pleuritic effusion. Extensive effusions must be aspirated. In all 
forms of pleurisy, even if the amount of fluid is not large, but per- 
sists, with a rise and fall of temperature, we should introduce a 
needle to determine the nature of the fluid. Pus should be evacuated 
from the pleura in the manner directed in the chapter on Empyema. 

Joints. — Joint-affections are best treated by immobilizing the 
affected articulations. The patient should be kept quiet, and sodium 
salicylate in liberal doses administered. If this is ineffectual after 
a few days, the joints should be wrapped in cotton moistened with 
oil of wintergreen, and sodium bicarbonate given in very liberal 
doses (grain x (0.7) for a child of three or four years, four times 
daily). If synovitis occurs and the fever continues high, the joint 
should be aspirated under antiseptic precautions, in order to ascer- 
tain if pus is present. If this is the case, an incision with drainage 
is the proper remedy. 



II. ROTHELN. 

( German Measles ; Rubella ; Trousseau^ s Roseola. ) 

Epidemics of this disease have been described by Forney, 1784 ; 
Heim, 1812 ; Hildebrand, 1832 ; and in recent times by Thomas 
and Orozer Griffith. It is an acute infectious disease, contagious 
from person to person through the atmosphere, though not as highly 
so as measles. It may occur in the same person a number of times, 
and may attack those who have had measles. All children exposed 
do not develop the disease. 

Age. — The youngest patient in the author's experience was seven 
weeks old. The affection may occur at any age. The author has 
met it in adults. It occurs with the same frequency in both sexes. 

Prodromal Period. — There is a prodromal period, during which 
there may be a slight suffusion of the eyes, with swelling of the con- 
junctival fold at the inner canthus of the eye. In two cases ob- 
served by the author the lymph-nodes behind the border of the 
sternomastoid muscle were observed to be enlarged six days before 
the appearance of the exanthema. There is no fever or constitu- 
tional disturbance. The period of incubation is placed by Thomas 



ROTHELN. 255 

and Emminghaus at from fifteen to twenty days. Just prior to 
the eruption there are headache, nausea, and bronchial irritation 
(Forcheimer, Emminghaus). 

Exanthema. — The exanthema resembles that of measles so 
closely that at the outset it is common for physicians to mistake one 
for the other. It is also similar in that it is first noticed to ap- 
pear faintly around the alse nasi and on the upper lips. The exan- 
thema appears first on the face, at the temporal regions, and on 
the cheeks. It is in some cases preceded by an erythematous blush 
diffused over the whole face (Emminghaus), which disappears in a 
few hours, leaving the true exanthema (pre-exanthematic erythema). 
The exanthema is papular, of a deep rose-red color, and distinctly 
arranged in crescentic outlines. This arrangement of the papules 
in circles and half circles can be made out where the eruption is 
spreading. On the face and neck it gives place to the blotchy ap- 
pearance characteristic of measles. As a rule, the eruption remains 
discrete. (Edema is rarely present. The papules have been de- 
scribed as of two varieties — one the size of those in measles, and 
the other punctate (Thomas). The punctate papules have been 
seen by the author on the upper part of the chest, where the erup- 
tion is confluent. They are likely to be mistaken in these cases 
for the exanthema of scarlet fever. In some cases of Thomas and 
of the author the punctate papules only were present over the whole 
trunk. There is an absence of the intense dermatitis seen in scarlet 
fever, and the individual roseolar spots have the outline above 
referred to. The exanthema, while fading on the face and chest, 
spreads slowly on the extremities. The exanthema remains dis- 
crete where it is spreading. It remains at its efflorescence on the 
face and trunk from a few hours to a day, when it begins to fade 
first from the face, and then from the trunk. A patient may pre- 
sent a perfectly normal skin twenty-four hours after the appear- 
ance of the eruption. Evidences of the eruption may remain on 
the trunk and skin for two or three days. The skin then may pre- 
sent bluish or brownish crescentic spots in place of the original 
exanthema, similar to what is seen in simple erythema. Four days 
after the eruption has appeared the skin in most cases will have 
a normal hue. There is no pigmentation or discoloration as in 
measles. 

Desquamation. — Desquamation is not always apparent. It is 
' possible in exceptional cases to see a very slight desquamation only 
at the upper part of the thorax or inner portion of the thighs. 

The Eruption on the Mucous Membranes. — In rotheln the 
eruption on the mucous membranes does not resemble the exanthema 
of the skin. There is an eruption in the mouth, but it is not char- 
acteristic. There is a mild injection of the conjunctiva, a redness 
of the fauces, and perhaps a slight cough. Coryza, photophobia. 



256 



THE SPECIFIC INFECTIOUS DISEASES. 



and bronchitis are absent. The mild angina and the injection of 
the conjunctiva resemble what is seen in la grippe. Thomas and 
Emminghaus have described an irregular, spotted, streaked appear- 
ance, with small grayish miliary vesicles, on the soft and the hard 
palate. Gerhardt has described a spotted hemorrhagic eruption on 
the palate, and Forcheimer an irregular macular rose-red eruption 
on the soft palate. None of these is constant or characteristic of 
rotheln, but all are found in other affections. The buccal mucous 
memhy^ane, however, is absolutely free from eruption of any kind, and 
in this fact we have a valuable diagnostic distinction between this 
disease and measl'es. In a small percentage of cases a few red stel- 
late spots on the buccal mucous membrane have been seen by the 
author. In no case, however, was the measles spot with its bluish- 
white central speck present. 

The temperature may at the outset be 99.8° F. (37.5° C.) in the 
rectum, and continue at this point throughout the disease. It may 

























Fig. 


34. 




























DAY OF 

MONTH 


1 


2 


3 


4 


DAY 


A.M. 


P.M. 


A.M. 


P.M. 


A.M. 


P.M. 


A.M. 


aQi° 
Sioo° 

1- 

99° 












































































































































































































































/ 












s 












































/ 












'"r 










































/ 














- 










































/ 


























































^ 




















































/ 




o 












O 








































/ 




^ 




\ 


























































\ 


























































\ 




i 












































a. 










— 


~- 






























































\ 


























































s 












^ 


X 












































N 








^ 


' 








■ — 








































N 


^ 


















■^ 


















































































































PULSE 


108 


116 


120 


120 


120 


108 


104 


RES P. 


24 


24 


24 


24 


20 


23 


20 



Temperature-curve of a case of rotheln in a boy six years of age. Observed from 

the outset. 



be 102° F. (38.8 "^ C), rarely higher. The temperature is highest 
at the outset when the exanthema appears on the face (Fig. 34). 
It falls rapidly within a few hours by a sort of crisis. Meanwhile 
the eruption may spread to the lower extremities. 

Lymph-nodes. — The author has observed a number of cases 
with especial reference to the lymph-nodes. Before the appearance 
of the eruption the nodes behind the sternomastoid and angles 
of the jaw may be enlarged. At the time of appearance of the 
exanthema the nodes of the axilla, bicipital groove, and groin become 
enlarged to the size of a bean or larger. The nodes may remain 
enlarged for weeks after the eruption has disappeared. 

The spleen is not enlarged. 



MEASLES. 257 

The Genitals. — In one case the injection of the vulvar mucous 
membrane caused temporary dysuria. 

Complications. — Rotheln is such a mild disease that complica- 
tions are rare. 

Prognosis. — The patients recover rapidly. 

Diagnosis. — The diagnosis of rdtheln should not present any dif- 
ficulties. It is most likely to be confounded with measles, scarlet 
fever, and erythematous eruptions. 

The symptoms are much milder, and there is an absence of the 
specific buccal enanthema of measles. Measles does not, as a rule, 
present simultaneous lymph-node enlargements all over the body, 
such as are seen in rotheln. 

Scarlet fever presents a severe dermatitis, which is absent in 
rotheln. There is a marked angina of a progressive type, with high 
temperature. The general enlargement of lymph-nodes is not so 
useful a sign, since in scarlet fever the lymph-nodes of the neck may 
be enlarged at the angle of the jaw, or those in the axillae and in the 
groin may enlarge as the eruption develops. In scarlet fever there is 
a characteristic desquamation. 

Erythematous eruptions of the small papular type may resemble 
rotheln, but the characteristic crescentic outline of the rotheln roseola 
is absent. 

Treatment. — Isolation need not be rigid. Children are kept 
indoors in summer until the eruption has disappeared and the tem- 
perature is normal. In the winter months the patients are kept 
indoors one week from the onset of the disease. The angina rarely 
requires treatment. 

III. MEASLES. 

{Rubeola ; Morhilli.) 

Measles is an acute infectious disease distinguished by a char- 
acteristic eruption on the mucous membranes and skin. It is 
highly contagious, and is propagated through the atmosphere. The 
specific agent has not been isolated. Most people are susceptible to 
measles, and suffer from at least one attack. Infants up to the 
age of five months are not as susceptible as at a later period. 
Newborn infants have been infected by the mother, and the foetus has 
been infected in utero. The foetus in such cases may be expelled 
prematurely, and at birth is found covered with the exanthema ; or, 
if the infection occurs at full term, the foetus may be expelled alive 
covered with the exanthema (Squire). The firstborn only is believed 
by Thomas to be immune for the period mentioned. The disease is 
very infrequent during the first year of life. Bartels calculates the 
occurrence at this time at 5 per cent, of the total number of cases. 
The author has seen measles in infants under five months of age. 

17 



258 THE SPECIFIC INFECTIOUS DISEASES, 

Measles is most frequent between the age of one and five years 
(Bartels, Henoch). It is prevalent in all countries of the globe ; 
climate or meteorological conditions seem to have no influence 
upon its prevalence either endemically or epidemically. 

Measles has a well-defined period of incubation, varying from 
thirteen to fifteen days (Van Panum). In calculating this period 
we include the time which elapses from exposure to the appearance 
of the eruption on the body. It will be seen later that this period 
includes the period of incubation proper, in which absolutely no 
symptoms, not even fever or malaise, are apparent, and the period 
of the enanthema on the mucous membrane. The enanthema, 
which may be accompanied by coryza of mild or severe type, may 
appear from the ninth to the tenth day after exposure, and lasts 
from three to five days. Thus while the coryza may be postponed 
several days or the enanthema may be present for a variable period, 
the two periods together have a duration of from thirteen to fifteen 
days. I have seen the enanthema fully five days before the exan- 
thema, and have seen cases of this kind without any manifestations 
of coryza to signalize the onset of the disease. It is erroneous, 
therefore, to calculate the period of incubation from the exposure 
to the onset of coryza, as the latter is variable as to the time of 
its appearance. 

One attack protects the individual from subsequent attacks. 
Authentic cases of two attacks in the same individual have recently 
been recorded. By this is not meant a recrudescence of the ex- 
anthema after it has once faded. This is also known to occur 
(Jiirgensen). Experiments have proved that measles is highly con- 
tagious in the catarrhal stage. Inoculations with the blood (Home) 
and nasal secretions (Mayr) have given positive results. The period 
of greatest contagion extends through the period of the exanthema. 
It diminishes as the exanthema fades, and is thought to disappear 
gradually during the period of desquamation. Thus though more 
general in its power to infect, the poison of measles has a shorter 
period of life than that of scarlet fever. The poison of the latter 
disease may retain its power of infection months after the disease 
has run its course. From what has been said, it will be under- 
stood that the infection in measles takes place in the vast majority 
of cases in the stage of the enanthema (incubation). At this time 
there may be no coryza. 

Infection occurs during the stage of desquamation (Baginsky). 
If ordinary caution is exercised, it is doubtful whether measles is 
ever carried by a healthy individual to a third person as scarlet 
fever is. Baginsky records an epidemic caused in this manner. The 
poison does not adhere to articles of furniture and wearing apparel 
with the same tenacity as in scarlet fever. 



MEASLES. 259 

The Ordinary Type of the Disease. 

The ordinary simple type of measles is that which runs its course 
without any complications or sequelse. There is a prodromal period, 
which includes the period of incubation before the appearance of the 
enanthema on the mucous membrane of the mouth. During this 
period it is well established that there are no clinical symptoms 
whatever — neither fever nor malaise. At the time of the appear- 
ance of the enanthema on the mucous membrane the patient begins 
to feel slightly ill. The symptoms may be only a headache or a 
slight disturbance of the stomach. The author has noted in some 
cases a rise of a degree or more in temperature toward evening. 
There are at this time slight injection of the eyes and general las- 
situde. Coryza is not pronounced. The patient during the first 
days of the enanthema, and by this is meant forty-eight to seventy- 
two hours before the appearance of the exanthema on the skin, pre- 
sents few signs of illness. If, guided by the very faint redness 
at the inner canthus of the eyes, we look into the mouth, a few 
spots of a very characteristic eruption are seen on the buccal mucous 
membrane. This eruption is pathognomonic of the invasion of 
measles, and will be later described as the enanthema. After forty- 
eight to seventy-two hours, and in some cases a longer period, there 
are coryza, cough, and conjunctivitis. There is a slight febrile 
movement, varying in intensity in different cases. The exanthema 
now appears, and is first noticed at the temporal region of the face 
and the alse nasi as a macular rose-red spotted eruption, which 
becomes papular later in the course of the disease. The face and 
scalp are now fully covered by the rose-red irregularly shaped 
papules, which next appear in rapid succession on the back of the 
hands, forearms, anterior part of the trunk, back, and lower extremi- 
ties. This order of the appearance of the exanthema is not always 
maintained. In some cases, as pointed out by Rehn, and verified 
by the author, the eruption may first appear on the back. It is, 
therefore, advisable to examine the patient in a nude state. 

The eruptive stage of measles generally lasts three or four days, 
during which the patient has an exacerbation of all the symptoms 
of the stage of invasion. There are intense photophobia, active 
coryza, and a croupy cough as a result of the invasion of the laryn- 
geal mucous membrane by the enanthema. The bronchi are also 
affected, and there are symptoms of acute bronchitis. Even very 
mild cases of measles show laryngeal and bronchial involvement. 
At this stage the exanthema on the skin is general and profuse, 
and in places confluent. The patches of healthy skin are crescentic, 
owing to the peculiar conformation of the papules. In some mild 
cases the rash may be very diffuse, but in others discrete. In the 
mildest forms of measles the rash closely resembles in the latter 
respect that seen in rotheln. 



260 THE SPECIFIC INFECTIOUS DISEASES. 

The fever reaches its height when the eruption on the skin is fully 
developed. If the mucous membrane is inspected at the height of 
the skin eruption, it will be seen that the enanthema becomes 
diffuse before the eruption of the skin is fully developed. The 
mucous membrane of the mouth is diffusely inflamed and studded 
with bluish-white specks which rapidly disappear or desquamate. 
The eruption on the skin persists for three or four days and then 
begins to fade. With disappearance of the eruption the general 
symptoms abate. The fever remits, and the temperature becomes 
normal by gradual morning remissions. The coryza, cough, and 
photophobia lessen, and the patient passes into the convalescent 
period. Desquamation begins when the pinkish hue of the eruption 
has disappeared. This stage continues until the last vestige of pig- 
mented spots on the skin has disappeared. As a rule, it is com- 
pleted two weeks after the exanthema has made its appearance. 
Desquamation is never absent in measles (Crozer Griffith), but it 
may be difficult to detect its presence. The epithelium is shed in the 
form of branny scales. Desquamation is best seen on the anterior 
part of the chest, shoulders, and inner surface of the thighs. In 
uncomplicated cases it is not attended by constitutional symptoms. 

The Temperature. — Measles presents no characteristic fever-curve. 
The invasion is rarely signalized by a chill. There may be a slight 
sensation of chilliness. The prodromal period before the appearance 
of the enanthema is not marked by fever. The period of the enan- 
thema presents a slight temperature with morning remissions to normal 
(Fig. 36). When the eruption appears on the skin the fever increases, 
and reaches its height after thirty-six hours, at the time of the full 
development of the eruption. The temperature continues high with 
morning or evening remissions for from one and a half to two and 
a half days, and then subsides, and disappears in from twenty-four 
to thirty-six hours after desquamation has set in. The temperature 
may reach 104°-105.8° F. (40°-41° C.) without complications. 
During the stage of desquamation the temperature is not elevated 
unless complication exists in the lung or elsewhere (Fig. 35). 

I have sketched the type of disease which is not complicated by 
serious affection of the viscera and which has no sequelae. On 
account of variations from the simple type just described, measles 
is one of the most dreaded diseases of infancy and childhood. 

In fatal cases occurring during the first two years of life the lung 
is generally involved (Henoch). The appearance of the eruption is 
ushered in Avith a convulsive seizure or a chill. The pneumonia 
appears as the eruption reaches its height, and within two weeks 
either proves fatal or else leaves the patient weakened or the subject 
of an empyema. The infection of the kidneys may be so severe as 
to prove speedily fatal, or there may be severe mastoid disease. On 
the other hand, there are cases of measles of a type so mild as to 



PLATE VII. 



Fig. 1. 



Fig. 





Fig. 3. 



Fig. 4. 





The Pathognomonic Sign of Measles (KopUk's Spots; 



Fig. 1. — The discrete measles spots on the buccal or labial mucous membrane, showing the isolated 
rose-red spot, with the minute bluish-white centre, on the normally colored mucous mem.brane. 

Fig. 2. — Shows the partially diffuse eruption on the mucous membrane of the cheeks and lips; patches 
of pale pink interspersed among rose-red patches, the latter showing numerous pale bluish-white spots. 

Fig. 3. — The appearance of the buccal or labial mucous membrane when the measles spots completely 
coalesce and give a diffuse redness, with the myriads of bluish-white specks. The exanthema on the skin 
is at this time generally fully developed. 



Fig. 4. — Aphthous stomatitis apt to be mistaken for measles spots. 
Minute yellow points are surrounded by a red area. Always discrete. 



Mucous membrane normal in hue. 



MEASLES. 



261 



cause little constitutional disturbance. The fever is very mild and 
evanescent, and present only at the outbreak of the eruption, and 
even at this stage may be so slight as to escape notice. Jiirgensen 
records measles without fever. 



Fig. 35. 


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Uncomplicated measles in a boy of five years. 

The Enanthema. — This is the eruption which appears on the 
mucous membrane of the mouth. It differs from the exanthema 
in respect to location. The enanthema appears in the mouth from 
three to five days before the appearance of the exanthema. It is 
accompanied by redness of the pharynx, and of the anterior and 
posterior pillars of the fauces. The soft palate is studded with 
irregularly shaped rose-colored spots or streaks. The spots on the 
hard palate present small w^hitish, punctate, miliary vesicles. These 
spots are also found on the otherwise normally colored mucous 
membrane of the cheeks and on that opposite the gums of the upper 
and lower molar teeth. They have been described by Flindt in 
these localities and on the palpebral conjunctiva. Filatow has de- 
scribed a desquamation of the epithelium of the mucous membrane 
of the lips and cheeks, in the form of minute whitish shreds (Slawyk). 
A complete series of studies of the enanthema of measles has been 
made, and there can, therefore, be no doubt of its existence. In 
1896 I published a study of the enanthema on the buccal mucous 
membrane, and on the inner surface of the lips. In this study 
I showed that the enanthema on the hard and soft palate so fre- 
quently described since the publication of Rehn was not peculiar 
to measles. The spots of rose-colored papules or streaks with the 
superimposed miliary vesicles are found in rotheln, scarlet fever, and 
some cases of simple angina. The eruption on the buccal mucous 
membrane alone, how^ever, preceding the appearance of the exanthema 
on the skin by a period of from three to five days, is characteristic 



262 



TBE SPECIFIC INFECTIOUS DISEASES. 



of the invasion of measles. It is pathognomonic of the disease, and 
occurs in no other known conditions. It is almost invariably pres- 
ent, observations having shown it to be absent in only a very small 
percentage of cases. 

On looking at the mucous membrane lining the cheeks (buccal) 
in strong sunlight, a very characteristic eruption of irregular stel- 

FiG. 36. 



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Case of measles observed from the first appearance of the " Koplik spots " to the time of 
the outbreak of the first signs of an exanthema, a period of fully four days. During this 
time it appears there was a gradually rising curve of temperature without any exanthema. 



late ' or round rose-colored spots is seen. In the centre of each 
spot there is a bluish-white speck. This appearance of a bluish- 
white speck on a rose-colored background is pathognomonic of the 
onset of measles. The speck is sometimes so minute that strong 
sunlight is necessary to render it visible. The number of specks 



MEASLES. 263 

at the outset may be less than half a dozen. In a short time they 
become more numerous, and the rose-colored spots become conflu- 
ent, so that there are diffusely red patches of buccal mucous mem- 
brane studded with bluish-white specks. The specks rarely or 
never become confluent ; their color does not resemble that of sprue, 
nor are they as coarse as sprue accumulations. They are seen on 
the inner surface of the lips, and are sometimes well marked on 
the buccal mucous membrane adjacent to the gums of the upper 
molar teeth. If the finger is passed over the mucous membrane, 
they are felt to be raised and firmly adherent. They can be 
rubbed off* by force or picked off wdth forceps. As the exanthema 
spreads, the enanthema of the buccal mucous membrane becomes 
difluse. When the exanthema is at its height and during efflo- 
rescence the eruption on the mucous membrane begins to lose its 
characteristics. The bluish-white specks are washed away by the 
buccal secretions and leave the mucous membrane diffusely red- 
dened and raw. 

By referring to the temperature-curve, it will be seen that the 
appearance of the enanthema is accompanied before the outbreak of 
the skin eruption by fever of a low type (Fig. 36). There is also 
at this time a leucopeuia ; a diazo reaction appears in the urine at 
the time of the outbreak of the exanthema. 

The exanthema of measles is a characteristic eruption of rose- 
colored or purple-colored papules, varying in diameter from 1 mil- 
limetre to 1 centimetre, the average diameter being 2 millimetres. 
They are irregularly circular, or longer in one diameter than another, 
or shaped like a half-moon. They arrange themselves crescentically. 
They are at first discrete, but soon become confluent, so that large 
areas of skin are covered. Here and there are areas of normally 
colored skin. The discrete papules have a distinctly crescentic 
arrangement. This is seen on the thorax and thighs. As a rule, 
the whole face is covered with the eruption, and the skin swollen. 
The eruption spreads from the face and head to the back of the 
neck, throat, upper part of the back, chest, and back of the hands 
and arms. The lower extremities become affected, as well as the 
palms of the hands and soles of the feet. As a rule, the eruption 
on the skin is papular ; the papules may show at their summit miliary 
vesicles. They may become confluent and form patches. Hemor- 
rhages may occur in and around the papules (Morbilli hsemor- 
rhagica). In these cases petechise occur in the course of the exan- 
thema, and persist into the period of desquamation. They should 
not be confounded with petechial eruptions or purpura, whidi may 
appear after the exanthema has run its course. The exanthema in 
weakly children may be limited in its distribution and not charac- 
teristic. Henoch believes that many cases in which the exanthema 
does not develop in sequence, take a subsequent course which may 



264 THE SPECIFIC INFECTIOUS DISEASES. 

be severe. If therefore the exanthema should first appear on the 
back, instead of the face, and spread thence, complications may be 
expected. Although complications occur with eruptions which are 
diffuse and very general, the severity of the eruption is no index as 
to the severity of the disease. 

When the exanthema fades, it leaves the skin studded with dirty 
brownish-colored spots, which have the arrangement of the original 
exanthema. These pigmented areas gradually fade, and when 
desquamation is complete they disappear. 

Measles may run its course without the appearance of the exan- 
thema on the face. It may be ill-defined and limited to certain 
parts of the body. It may develop in full intensity and then sud- 
denly fade within a few hours. This occurs in cases in which 
severe disturbances of the circulation alter the distribution of blood 
in the skin. In these cases there may be a complication of the 
lungs or heart, but the fading of the exanthema is not, as is thought 
by the laity, primarily the cause of any affection of the internal 
organs. 

The Nose, Pharynx, and Larynx. — In very young infants severe 
inflammation of the mucous membrane of the nose and nasopharynx 
may lead to difficulties not only in breathing, but also in feeding. 
In these cases membrane rarely develops. If it does appear, it takes 
the form of a pseudomembranous rhinitis, generally of a diphtheroid 
streptococcic nature. Its course then may be subacute. The larynx 
is sometimes severely affected, so that at the height of the exan- 
thema the patient is troubled with a harassing, croupy cough. In 
some cases the patient becomes almost aphonic. If there is no 
obstruction to the breathing, this symptom, which causes great con- 
cern, disappears. The larynx may present a pseudomembranous 
affection of a streptococcic nature. Gerhardt has shown that ulcer- 
ation of the posterior laryngeal wall may ensue from traumatism to 
the larynx as a result of repeated fits of coughing. If these ulcera- 
tions cause swelling of the mucous membrane, obstruction to respira- 
tion may result. The bronchitis which is always present in such 
cases may cause obstruction of the finer bronchi. On account of inef- 
ficient respiratory effort atelectasis and pneumonia may result, with 
fatal issue. 

Diphtheria may complicate measles. It may precede the erup- 
tion, or may develop at any time during the attack. In all such 
cases the patient has been exposed to a double infection. In one 
case in the author's hospital service the patient had recovered from 
diphtheria two weeks previous to the attack of measles. Three 
days after the appearance of the exanthema the conjunctiva became 
covered with true diphtheritic membrane. The larynx then became 
involved, and stenosis set in within twenty-four hours after the 
appearance of the membrane on the conjunctiva. The exanthema 



MEASLES. 265 

in these cases is likely to fade rapidly or become hemorrhagic. 
Cases of diphtheria complicated with measles are rapidly fatal, since 
the trachea and bronchi become involved. Fatal pneumonia super- 
venes. On the other hand, the author has seen a croupy cough with 
dyspnoea, set in three weeks after convalescence from measles. 
Diphtheria bacilli were found in the pharynx, and yet recovery 
took place. In this case no pseudomembrane on the pharynx was 
visible. It is not always possible to decide in a given case whether 
there is a simple swelling of the mucous membrane of the larynx 
or a pseudomembranous process. In cases with severe laryngeal 
symptoms, if no membrane is visible, a culture of the secretions of 
the pharynx should be made. The temperature-curve does not aid 
us. Diphtheria may run its course with a low or a high tempera- 
ture. The pulse is of little assistance in making a diagnosis. There 
is nothing in the nature of measles which predisposes tow^ard diph- 
theritic infection. 

During convalescence persistent hoarseness or aphonia is not 
infrequently seen without other disturbances. The voice gradually 
returns to the normal.^ 

Bronchitis ; Bronchopneumonia ; Atelectasis. — A very serious com- 
plication of measles is bronchitis, which may involve the capillary 
bronchi, causing atelectasis and bronchopneumonia. In the stage 
of efflorescence the bronchitis at times becomes severe. There are 
found on auscultation fine crepitant rales in addition to the very 
coarse mucous and sonorous rales. At the end of inspiration a 
fine crepitation is heard, similar to that present at the beginning 
of pneumonia. There is also subcrepitation at the close of expi- 
ration. In these cases the constitutional symptoms are severe, 
if large areas of lung are involved. The dyspnoea is extreme. 
Although cyanosis may be present, no areas of consolidation are 
detected on physical examination. It is reasonable to infer that 
in all the cases of severe inflammation of the smaller bronchi, areas 
of bronchopneumonia exist. Auscultation may reveal areas of lung 
in which the air enters imperfectly. An attack of coughing will 
open up the bronchi, when air again enters these areas (atelectasis). 
In young infants and children this form of bronchitis is a serious 
complication. As a rule, it leads to bronchopneumonia. 

The pneumonia which complicates measles, either in the eruptive 
stage or in the desquamative period, is anatomically usually of the 
bronchopneumonic type, although the lobar form may occur. The 
pneumonia is caused by an invasion of the lung tissue by strep- 
tococci from the bronchi. A bronchopneumonia may at first be 

^ Prudden and Northrup, in a paper on diphtheria with fatal pneumonia, 
record 3 cases of fatal diphtheria complicating measles. The diphtheria and subse- 
quent pneumonia were of the streptococcus variety. The 3 cases formed part of a 
series of 17 cases of streptococcus diphtheria followed by pneumonia. 



266 THE SPECIFIC INFECTIOUS DISEASES. 

difficult of detection. As a rule, however, it involves a lobe of 
the lung in a short time. The lower portions of the lung behind 
are usually first involved, although the upper lobes or middle lobe 
may in exceptional cases be first involved. When consolidation 
takes place, the area of lung involved may be as extensive as in 
lobar pneumonia. A pneumonic process should be suspected if 
the temperature in the stage of desquamation does not fall to the 
normal. There is a distinct rise of temperature which varies in 
intensity, and remits in the morning to become higher in the even- 
ing. The cough becomes troublesome, and there is also dyspnoea. 
In such cases the temperature alone cannot be relied upon for a 
diagnosis. A careful physical examination will be of assistance. 
Under two years of age this form of bronchopneumonia is very 
fatal. As a rule, pneumonia complicating measles terminates, if not 
in immediate recovery, in a bronchopneumonia which persists for 
weeks. The temperature may fall almost to the normal in the morn- 
ing and in the evening rise a degree or more. In addition to the 
bronchopneumonia there may be pleurisy, with thickening of the 
pleura and purulent exudate. In some cases the upper lobe of the 
lung shows signs of unresolved pneumonia for weeks. Emaciation 
is progressive. All of these cases are not necessarily tuberculous. 
A tuberculous process may be engrafted on a non-tuberculous 
bronchopneumonia at any time by infection with tubercle bacilli. 
In measles there seems to be a predisposition to iuv^asion of the 
lung by tubercle bacilli through the catarrhal and inflamed mucous 
membrane of the bronchi. We can reasonably hope for recovery in 
many of these cases of simple chronic bronchopneumonia. If tuber- 
culous glands, which have been dormant before the invasion of 
measles exist, they form focal points for the development of tuber- 
culosis of the lungs or meninges. Such cases are fatal. Autopsy 
will reveal recent lesions alongside of old tuberculous foci. 

The frequency of infection with tuberculosis varies in different 
localities. In some epidemics it occurs in 5 per cent, of the cases ; 
in others, 16 per cent, or more are affected (Bartels, Jiirgensen). 

The Heart. — The endocardium is rarely affected in measles. If 
endocarditis does occur, it is usually an intercurrent affection in a 
rheumatic subject. Fig. 37 shows a temperature-curve from a case in 
which rheumatism preceded an attack of measles, and which in turn 
was followed by endocarditis. Myocarditis may be found in fatal 
cases of bronchopneumonia. In bronchopneumonia complicated 
with pleurisy, pericarditis may also be present (Baginsky). 

The Intestines. — In some epidemics diarrhoea is a frequent com- 
plication. The movements are numerous, and watery in character. 
When the large intestine is involved the stools contain blood and 
mucus, and tenesmus is present. The season of the year influences 
the intensity of the infection. In the warm months the diarrlioea 



MEASLES. 



267 



may be of a severe type. In cases recorded by Henoch and Thomas, 
autopsy showed enlarged Peyer^s patches and solitary follicles resem- 
bling those seen in typhoid fever. No cases of ulceration have been 
recorded. Jiirgensen is inclined to consider the diarrhoea a result of 
infection of the intestinal mucous membrane. The enanthema appears 
in this locality early in the disease. 

The Kidneys. — In many cases of measles, albumin and a few 
hyaline and epithelial casts are present in the urine. They are the 
result of a parenchymatous inflammation of the kidney, due to the 
poison of the disease. A true nephritis, such as is common in 
scarlet fever, is rarely seen. Nephritis is apt to occur in the severe 





















Fig. 37. 






















DATE 


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9 


10 


11 


12 


13 


14 


15 


16 


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18 


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19 


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23 


24 


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27 


28 


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PULSE 


102 


118 


116 


124 


132 


124 


134 


140 


140 


132 


140 


146 


136 


140 


140 


128 


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RESP. 


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Measles complicated with endocarditis in a boy six years of age. 



cases complicated with bronchopneumonia. There may then be 
marked albuminuria, blood, and casts of all kinds in the urine, with 
suppression. On the other hand, nephritis in the stage of desqua- 
mation is rare. There is always in such cases suspicion that an 
infection coincident with scarlet fever may have been overlooked 
(Henoch). If diphtheria complicates measles, nephritis is likely to 
be present. 

The Bones and Joints. — The author has seen osteomyelitis with 
suppuration of the joints follow measles. Streptococci were found 
in the pus. In one case bronchopneumonia was an earlier compli- 
cation. These cases are rare. 

Lymph-nodes. — If the inflammation of the throat is severe, the 
lymph-nodes at the angle of the jaw and underneath the body of the 
jaw may be enlarged. Harely, however, is the adenitis as severe as 
in scarlet fever. The glands or nodes in the axillae, bicipital groove, 
over the internal condyle of the elbow-joint, and in the groin may be 
enlarged to the same extent as in rotheln, as a result of the processes 
taking place in the skin. Severe infection of the gut may cause 



268 THE SPECIFIC INFECTIOUS DISEASES. 

swelling of the mesenteric lymph-nodes, which, if not tuberculous, 
will retrograde after the disease has run its course. 

The Blood. — In measles as distinguished from scarlet fever an 
examination of the blood shows a subnormal number of leucocytes 
or a leucopenia. This condition of the blood is found in the initial 
stage of the disease, and persists well into the period of the exan- 
thema in uncomplicated cases, as is well shown in Fig. 36. 

The Nervous System. — It is rare to see convulsions usher in an 
attack of measles, ev^en of a severe type. In anomalous forms of 
the disease complicated with pneumonia there maybe cerebral symp- 
toms similar to those seen in the latter affection. There may in 
some cases be a complicating cerebrospinal meningitis with purulent 
exudate. If tuberculosis is present, the meninges may be attacked, 
as in any tuberculous infection. French writers have observed 
neuritis following measles. 

The Eyes. — Following severe cases of measles, photophobia, spasm 
of the orbicularis, inflammation of the lachrymal duct, conjunctivitis, 
ulcerations of the cornea, and amaurosis may result. Hence, even 
in mild forms of the disease the eyes should be frequently inspected 
(Eversbusch). 

The Genitals. — The author has seen dysuria in cases in which the 
enanthema affected the mucous membrane of the vulva in girls. 
Henoch records cases of gangrene (noma) of tht> genital organs. 

The Mouth. — Inasmuch as the mucous membrane of the mouth 
is the seat of an active eruption, stomatitis is likely to be present, 
especially if through carelessness or traumatism the mucous mem- 
brane has become infected with bacteria from without. In such 
cases aphthae may result. Children in unhygienic surroundings 
are likely to develop noma of the cheek if exposed to the infection. 

Pertussis as a complication of measles is occasionally found. As 
in diphtheritic infection, there must have been exposure to the con- 
tagion of both pertussis and measles, since etiologically the diseases 
have nothing in common. The danger in the coincident occurrence 
of measles and pertussis is that bronchopneumonia is likely to 
develop, and prove a serious if not fatal complication. 

The Ear. — The external structures of the ear may be afiected by 
oedema and swelling. The external auditory canal may become the 
seat of painful swelling and diffuse inflammation. Gangrene of the 
pinna has been noted (Nottingham, Bourdillot). The most common 
affection of the ear is otitis media catarrhalis. Of 33 cases of 
severe complicated measles, Tobeitz found otitis of this variety in 
16. The frequency of otitis varies with difterent epidemics. The 
otitis makes its appearance in the period between the seventh and 
the twenty-sixth day following the development of the exanthema. 
Of 22 fatal cases of measles, otitis was found in 19, only 7 of which 
presented symptoms during life. The great majority of cases of 
otitis give no pronounced symptoms and end in resolution. These 



MEASLES. 269 

mild cases are the result of the action through the blood of the 
measles poison on the ear structures (hsematogenic). The severe 
cases follow a mixed infection through the pharynx and Eustachian 
tube. In the pus of acute or chronic otitis, with or without inflam- 
mation of the mastoid, the streptococcus, Staphylococcus pyogenes, 
and pyogenic diplococci have been found. The general course of 
otitis is not so severe as that of scarlet fever. In some epidemics 
the severe and fatal cases are more common than in others. 

Sequelse. — Any of the complications named above may pursue 
a chronic course. In this sense only are they sequelse. Chronic 
blepharitis, blennorrhoea, keratitis, otitis, catarrhal inflammation 
or ulceration with stenosis of the lar}mx, septic retropharvmgeal 
abscess, and chronic bronchopneumonia may persist for weeks or 
months. 

The prognosis in measles varies with the virulence of the epi- 
demic, the resistance of the individual, and the age of the patient. 
It is certain that the idea prevalent among the laitv^, that measles 
is a comparatively mild afl'ection, is incorrect. In the cases treated 
in both dispensary and private practice, and at all periods of infancy 
and childhood, the mortality is 8 per cent. (Breyer). The mortality 
is greatest during the first year of life, and may varv^ in different 
epidemics from 10 to 40 per cent. The lowest mortality seems to be 
between the fifth and eighth years — 6 per cent. (Baginsky). Hos- 
pital statistics are of little value to the general practitioner, as the 
class of cases treated in these institutions give a high mortality- 
rate. The mortality in hospitals may be as high as 30 to 35 per 
cent. (Henoch, Fiirbringer). 

The diagnosis will in most cases present few difficulties if the 
physician follows a fixed routine in the examination of the patient. 
The mode of onset, the coryza, the enanthema of the buccal mucous 
membrane, and the skin eruption are characteristic. If the physician 
will examine the inner surface of the cheeks and the buccal mucous 
membrane in every seemingly slight indisposition of children, he 
will in certain cases be able to predict an attack of measles far in 
advance of the appearance of the exanthema. In some cases the 
enanthema appears on the buccal mucous membrane before coryza is 
present. The inspection of the buccal mucous membrane thus 
becomes important as a prophylactic measure. Strong sunlight is 
essential for thorough inspection. Although the bluish-white spots 
on the rose-red background may sometimes be seen by artificial light, 
especially electric light, a diagnosis of measles should never be made 
at night. Cases of influenza closely resemble measles at the outset. 
These present the injected conjunctivae, cough, and rose-colored 
spots on the soft and the hard palate seen in measles. In la grippe, 
however, the buccal mucous membrane is pale and presents abso- 
lutely no eruption. In one of the early grippe epidemics in Xew 



270 THE SPECIFIC INFECTIOUS DISEASES. 

York the children showed an ill-defined roseolar eruption on the 
surface, but the buccal eruption was never present. 

Rotheln in some cases resembles mild measles so closely that the 
author has often questioned whether so-called cases of mild measles 
without rise of temperature, described by authors, were not cases of 
rotheln. The difficulty in differentiation is increased if measles is 
prevalent at the same time. The absence of the buccal eruption is a 
crucial test. Schmid has also laid stress on this point. In some 
rare cases of rotheln there may be seen an isolated rose-red spot 
here and there on the buccal mucous membrane, but the bluish- 
white speck in the centre of these spots is never seen as in measles. 

Scarlet fever may at times closely resemble measles, especially 
in those forms in which the eruption on the face is evanescent. In 
scarlet fever the buccal mucous membrane has a normal hue. 
The author has seen scarlet fever complicated Avith measles. In 
these cases the scarlet eruption appeared first. Within two or three 
days there was a general recrudescence of the exanthema, with the 
appearance all over the body of a roseola (the scarlet rash had 
faded somewhat), coryza, and the buccal eruption. In other cases 
the scarlet fever eruption on the back of the hands and forearms 
assumes the blotchy, papular roseolar form of the exanthema of 
measles. The author has seen a case of this kind in which an expert 
entertained the possibility of r5theln or measles. The buccal enan- 
thema was absent. The subsequent course of the case proved the 
diagnosis of scarlet fever to be correct. 

The roseola of typhoid is sometimes so abundant as to mislead 
the physician into mistaking it for the eruption of measles. Measles 
complicating tyj^hoid at the end of the second week has come under 
the author's notice. In this case the buccal eruption was ])rofuse. 

Antitoxin and drug eruptions may simulate a measles eruption, 
but the buccal mucous membrane never presents the enanthema. 

The roseola of syphilis frequently resembles that of measles so 
closely as to cause uncertainty in the diagnosis. Here the conjunc- 
tivae may be injected, and there may be a slight febrile disturbance 
(Sobel). The buccal mucous membrane is pale, and shows no erup- 
tion resembling that seen in measles. 

The diagnosis of measles thus resolves itself into a recognition 
of the disease before and after the appearance of the skin eruption. 
Before the appearance of the eruption there is very little to guide 
us. Cough, coryza, and fever may accompany an influenza. In 
these cases the buccal eruption is of great diagnostic value. After 
the eruption appears, the question narrows itself to the differentia- 
tion of measles from rotheln or scarlet fever, and the recognition 
of the various forms of erythema, roseola, drug and antitoxin erup- 
tions. 

Treatment. — Prophylaxis.— As soon as the physician has made 



MEASLES. 271 

the diagnosis of measles or suspects its presence, the patient should 
be isolated from the other children of the family. Among the poor 
it is sometimes impossible to do this. The members of the family 
not directly concerned in the care of the patient should be denied 
admittance to the sick-room. It is not necessary to cover the door 
of the room with cloths or sheets moistened with disinfectants. The 
physician before entering the room should take off his coat and put 
on some convenient linen gown or bath-robe, so as to completely 
cover his person. This robe should hang outside the door of the 
room, so as to be easily accessible. When not in use, it should be 
hung in the open air. If the physician wears a beard, he should 
wash it after leaving the patient, for if the patient coughs in the 
physician's face, he is likely to carry the infection in his beard to 
the next child visited. Should the measles be complicated with 
diphtheria, extra precaution is necessary. 

General Treatment — A typical mild case of measles needs little 
medicinal treatment. We try to make the patient comfortable. The 
temperature of the room should be about 68°-70° F. (20°-21.1° 
C), if possible. The ventilation should be constant and attained 
by means of opening doors and windows of rooms communicating 
with the sick-room. It is not necessary to darken the room very 
much ; in fact, Bartels has shown that light and air are necessary to 
the comfort and well-being of the patient. The author has found 
that the ordinary yellow window-shade, if drawn over the windows, 
sufficiently excludes the actinic rays which are irritating to the eyes. 

In a typical case of measles a temperature of 104°-104.5° F. 
(40° C.) may be ignored. It should be remembered that the fever 
continues only during the period of the eruption. With the fading 
of the exanthema the temperature becomes normal. It is only in 
cases in which there is a high temperature with delirium that 
medication is called for. It is not uncommon to see children cov- 
ered with an eruption and with a temperature of 104° F. (40° C.) 
playing in bed with toys. 

The cough will sometimes need treatment. In such cases I 
am accustomed to prescribe TTL iv (0.25) of paregoric combined with 
1TL ij (0.12) of syrup of ipecacuanha, every three hours. If the 
patient is kept awake by the cough, a small dose of Dover's powder 
(grains j or ij) (0.06 or 0.12) or codeine (grain yL- to \) (0.006 to 
0.008) at night will be sufficient. If the patient is very restless at 
night and we do not wish to give opiates, grains v (0.3) of trional 
will quiet a child of five years. Some young children can be put to 
sleep by a small dose of phenacetin (grains ij) (0.1). In a mild case, 
especially if there is pruritus or irritation of the skin, there is no 
objection to sponging the patient once a day with water at 100° F. 
(37.7° C), containing some alcohol or a pinch of sodium bicarbonate. 

The food should be light. Milk, broths, and, when the fever has 



272 THE SPECIFIC INFECTIOUS DISEASES. 

defervesced, chicken, soft-boiled eggs, jelly, toasted bread, crackers, 
rusk {Zwieback), and cereals in attractive form, with cocoa, comprise 
the diet list. Orange-juice or weak lemonade may be given in mod- 
eration. Water-ices may be given, if desired. 

As soon as desquamation has set in, I direct the body to be 
anointed every second day with an ointment of washed benzoinated 
lard combined with 5 per cent, of boric acid. The patient is 
allowed to get out of bed as soon as the temperature has fallen to 
normal, and is permitted to go out of doors three weeks after the 
outbreak of the eruption in the summer and four weeks in the winter 
months. Before mingling with other children, the patient should be 
thoroughly washed with soap. It is not necessary to put an anti- 
septic in the bath. 

The Treatment of Complications. — Bronchitis ; Bronchopneu- 
monia. — A severe inflammation of the finer bronchi is likely to 
cause as much fever, dyspnoea, cough, and restlessness as a primary 
bronchopneumonia. The temperature then rises and continues ele- 
vated— 104°, even 105° F. (40°-40.5° C.)— with morning remis- 
sions. In these cases the temperature must be reduced. I never 
hesitate to utilize hydriatic measures. The most convenient mode 
of applying water is by means of compresses moistened with water 
at 80° F. (26.5° C). If the patient reacts well, the compresses may 
be applied at 67° F. (19.4° C.) ; if he becomes cold and cyanosed, 
at 105° F. (40° C). These warm compresses are at times very 
soothing, causing the patient to drop into a quiet sleep. It should 
be remembered that the object of applying the compresses is not 
always to reduce temperature rapidly, but rather to stimulate the 
heart and support the patient. Douching the head with ice-cold 
water, as recommended by some, is a very questionable practice. 
The use of the coal-tar antipyretics should be avoided. In lower- 
ing the temperature they act as depressants. In severe cases of 
bronchopneumonia aconite should not be used to lessen the rapidity 
of the pulse. Caffeine, camphor, strychnine, and digitalis in proper 
doses are more satisfactory. If a bronchopneumonia be prolonged 
into the convalescent stage, we should be on the alert for pleuritic 
effusion. This is especially likely to occur if the pneumonia lasts 
longer than two weeks. In these cases the symptoms present are 
similar to those described under Pleurisy, and the treatment is 
carried out on the same principles. 

The LARYNGEAL SYMPTOMS bccome harassing when there is much 
swelling or slight erosions of the laryngeal mucous membrane. In 
such cases an improvised tent should be erected over the crib or bed 
and filled with steam vapor saturated with thymol or turpentine. 
Older children can be persuaded to breathe the vapor generated in an 
open kettle. If symptoms of stenosis appear, it must at once be 
determined by culture whether a diphtheritic process, a streptococcic 



VARICELLA. 273 

pseudomembranous formation, or a stenosis due to simple catarrhal 
oedema of the mucous membrane is present. 

Diphtheria. — Antitoxin is indicated in diphtheria either of 
the conjunctiva, pharynx, or larynx. A large dose should be 
given at the outset, on account of the virulent nature of this affec- 
tion as a complication of measles. We should not be too ready 
to intubate on the first appearance of stenotic symptoms. Many 
of these cases improve. The introduction of a tube into the 
inflamed larynx in measles is not without danger of causing ulcer- 
ations of a troublesome type after the measles has run its course. 
It is well to follow O'Dwyer's advice in such cases — withhold 
the tube as long as dangerous dyspnoea is absent. The use of 
apomorphine, tartar emetic, or turpeth mineral, so popular with 
continental physicians, to expel membrane or secretion, is of doubtful 
value. 

The Ear. — Otitis should be suspected if there is restlessness 
and an intermittent course of temperature without apparent cause. 
Older children may indicate the seat of pain. In some cases it may 
be necessary to incise the tympanic membrane. The procedure 
affords relief from pain, and is without ill effects. Pus or a few 
drops of serum only may be evacuated. 

DiARRHCEA requires the same treatment as a primary enteric 
catarrh. 

The care of the eyes, nose, and mouth should be conducted 
on general lines. If the secretion is excessive, the eyes may be 
bathed once a day with a lukewarm weak saline solution. Unless 
the secretions are excessive, the nostrils should not be syringed or 
douched. If clots of mucus or pseudomembranous shreds form in 
plugs, they may be dislodged once a day by a nasal washing with a 
suitable hand syringe. The mouth should not be washed more than 
once a day. This should be done both for infants who are fed 
artificially and for older children. On account of the great vulner- 
ability of the mucous membrane in this disease the utmost gentle- 
ness should be exercised lest aphthous ulceration be developed. 

IV. VARICELLA. 

{Chicken-pox ; (Ger.) Windpocken.) 

Varicella is an acute infectious disease with a characteristic exan- 
thematic eruption. It is distinct from vaccinia or variola, is an 
affection of childhood, occurring before the tenth year, rarely later, 
and is transmitted through the atmosphere. It cannot always be con- 
veyed by inoculation, as is the case with vaccinia or variola. It 
does not protect from vaccinia or variola. Varicella, vaccinia, and 
variola have been observed to attack the same patient successively 
at very short intervals. Fcav children escape after exposure, and one 
1§ 



274 . THE SPECIFIC INFECTIOUS DISEASES. 

attack does not confer immunity. Varicella is an endemic disease/ 
and does not occur epidemically. 

Incubation. — Varicella has a period of incubation during which 
competent observers have noted no disturbances (Henoch) ; others 
record malaise, coryza, and sore throat. The author is inclined to 
regard the prodromal period as free from symptoms. The period of 
incubation is usually fourteen days, but it may be protracted for 
nineteen days. 

The symptoms consist of an exanthema, an enanthema, fever, 
and slight malaise. There may be complications. Previous to the 
appearance of the exanthema there may be a slight febrile move- 
ment and malaise, which in children may pass unnoticed. In 
cases pursuing a normal course, a chill with a marked rise of tem- 
perature may precede the eruption by fully twelve hours. When 
the eruption appears the temperature gradually falls, unless another 
crop of papules appears, when there is another sharp rise of tem- 
perature. Sore throat and slight malaise may herald the eruption. 
Previous to the appearance of the rash there may be, as in measles 
and in varioloid, an erythema of the surface prior to the appearance 
of the exanthema. 

The exanthema consists of an eruption of roseolar papules varying 
in size from that of a pin's head to that of a split pea. They first 
appear on the forehead and face, and spread to the trunk. In some 
cases larger blotches appear, but these are of the nature of an 
erythema, which may precede the eruption of the roseola by a few 
hours. The roseolar papules have a characteristic violet-rose tint, 
are raised above the surface, and are sometimes hard to the touch. 
In a few hours the papule develops on its summit a vesicle, which 
rapidly fills with lymph. These vesicles become tense, and if the 
papule is irregular in shape cover the whole upper surface of the 
papule. In many places the vesicle at the stage of its efflorescence 
presents an umbilication which strongly resembles that seen in the 
vaccinia pock. The contents of the vesicle become cloudy and then 
yellow ; the vesicle is surrounded by a dusky pink areola. In the 
course of a day or two the cycle is completed, and the vesicopustule 
begins to desiccate. A reddish-brown scab is developed. Many 
of the roseolar papules do not develop the vesicle and pustule. 
While one crop of papules is going through the cycle described 
above, others appear on various parts of the body. It is character- 
istic of varicella to have the surface covered with roseolar papules, 
papules with vesicles, and with pustules, in various stages of develop- 
ment. The papules vesicles, or pustules may be few or very abun- 
dant. In some cases after the scab of the vesicle has fallen off a 
distinct scar is left, similar to that seen in vaccination, but much 
smaller ; it may persist for years. The skin between the papules 
and vesicopapules is normal in color. 



VARICELLA. 



275 



The soft palate and sometimes the hard palate may show a few 
isolated papules, vesicles or vesicopustules similar to those seen on 
the cutaneous surface (enanthema). In most cases there is an 
angina, an injection of the conjunctivae or even an enanthema on 
the ocular conjunctiva (Henoch). Thomas records varicella papules 
and pustules on the nasal and vulvar mucous membrane (Fig. 38). 

The temperature is in many cases little raised above the normal. 
In others it reaches 103° F. (39.4° C.) at the outset of the aifec- 
tion. In rare cases 106.5° F. (41.3° C.) has been observed. As 



Fig. 38. 


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STOOL II III 1 II 



Varicella temperature-curve showing successive rises 
vesicles. Boy aged six 



due to a new eruption of papules and 
years. 



soon as the eruption is fully developed the temperature rapidly 
becomes normal. The duration of the fever varies from one to 
three days. I have seen severe cases in which the high temperature 
persisted fully a week. The eruption was in these cases accom- 
panied by secondary pustulation. 

Other Symptoms. — Many infants and children show little consti- 
tutional disturbance. In other cases there is lack of appetite with 
excessive irritability. In others, on account of the profuse eruption 
in the vulva and around the nates, there is annoying vesical tenes- 
mus and even rectal tenesmus. The latter condition I have seen in 
a child two and a half years of age, in whom there w^as a profuse 
eruption of vesicles in and around the introitus vaginae, on the 
nymphae, and around the anus. There is in some cases a recru- 
descence of the exanthema in various parts of the body, with rises 
of temperature. 

Complications. — Gangrene of the skin with sloughing of large 
areas has been noted by some observers (varicella gangrenosa). 



276 



THE SPECIFIC INFECTIOUS DISEASES. 



The conclusion is inevitable that in many of these cases there must 
have been a mixed infection. 

Nephritis. — In many cases there is albumin in the urine to the 
extent of a trace. Henoch has described 6 cases of varicella compli- 
cated with nephritis on the eighth to the fourteenth day after the 
appearance of the eruption. In these the eruption was profuse and 
accompanied by fever ; there was oedema with albumin and casts in 
the urine. One case with fatty liver and moderate hypertrophy and 
dilatation of the left ventricle resulted fatally. Other authors 
have confirmed the observations of Henoch. I have seen slight 
albuminuria in some cases of varicella. 

Joint-affections. — I have observed two cases of varicella with 
swelling, pain, and effusion in one or both knee-joints. In 
neither was there suppuration. Both cases retrograded, and in a 
few days the joints became normal. The whole picture simulated 
what is seen in some cases of scarlet fever. There was no endo- 
carditis. 

Otitis may occur as a complication of severe cases. 

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Varicella bullosa, pneumonia, otitis media purulenta. Female child aged six years. 

The diagnosis of varicella should present few difficulties. I 
have seen a number of cases in which the eruption was not 
only very profuse, but the individual varicella vesicles or pus- 
tules were also very large. In these cases there may always arise 
the question of differentiation from the more serious affection, 
variola or varioloid, especially if an epidemic of smallpox is preva- 
lent. The diagnosis may even in some rare cases remain in doubt 
(Jiirgensen). In varicella the temperature is lower and the rise 
shorter in duration than in even a mild case of smallpox. In the 
absence of an epidemic, the mildness of constitutional symptoms, 
discreteness of the varicella eruption, and the absence of any oedema 
of the skin between the vesicles will aid us. 

In some cases the eruption of roseola papules on the face and 
trunk has not the characteristic appearance of vesiculation or pustu- 
lation seen in varicella. It is difficult on account of the eflPects of 



VACCINATION. 277 

the scratching of the patient to differentiate the eruption from pus- 
tules of a furuncular type. Under such conditions a close inspection 
of the back may result in the discovery of one or two typical 
varicella vesicles. 

The prognosis is very good in varicella, except in neglected 
cases, in which sepsis may complicate the disease. The very rare 
cases of nephritis (Henoch) should be borne in mind. In private 
practice and in a large ambulatory clinic I have rarely seen the 
severer types of this disease. I agree with Fiirbringer in thinking 
that such cases raise the question of the possibility of an extraneous 
infection. 

Treatment. — Though the course of varicella is mild, the cases 
should be isolated like those of any other infectious contagious dis- 
ease. We can never predict the outcome of a number of cases 
occurring in epidemic form, although individual cases do Avell. If 
there are itching and tension, the eruption is covered with 5 per cent, 
boric acid ointment applied without lint. The children are allowed 
out of doors as soon as the temperature has become normal, the 
scabs of the varicella vesicles or pustules have fallen off, and the 
skin has become normal. 



V. VACCINATION. 

Vaccination is a prophylactic measure against variola practised 
on the human subject. It gives a certain, though not lasting, 
immunity against the disease. It is accomplished by inoculating 
the human subject with the contents of the cowpox vesicle. 

Cowpox or vaccinia (vacca, cow) is a specific exanthema which 
occurs on the udder of the milch cow, hence the name. Vaccinia 
is inoculable from animal to animal, and also on the human subject. 
It occurs only at the point of inoculation. 

Successful vaccination gives the human subject almost certain 
protection for a long time against vaccinia or cowpox and variola or 
smallpox. 

The essential cause of vaccinia in animals and the human subject has been 
described by Guarnieri and Kurlow as vaccine corpuscles. These are found 
in the vaccine vesicle and pustule. They are peculiar, finely punctate, 
amoebic masses of protoplasm, showing vacuoles. Loudon and Salmon, on 
the other hand, deny any specific properties to these corpuscles. They think 
they are simply degenerated leucocytes, and are seen in other simple forms 
of inflammation, 

^ Edward Jenner (1749-1823) was the first to establish the doc- 
trine of vaccination on scientific experimental data. He was the 
first to use humanized vaccine — that is :o say, to inoculate the human 
subject with lymph from a cowpox vesicle, and then to utilize the 
lymph of the vesicle in the human subject to inoculate others. This 
method has been abandoned. To-day the lymph used is obtained 



278 THE SPECIFIC INFECTIOUS DISEASES. 

directly from the animal. The lymph is, as a rule, inoculated from 
animal to animal for several generations. It is just as effective as 
the lymph of the first animal of the series inoculated. It is called 
animal lymph or vaccine. The disadvantages of using humanized 
vaccine are many. First, there is a natural reluctance among some 
people to vaccinate their children with lymph obtained from the 
human subject. Apart from the popular belief in the transmission 
of tuberculosis, scrofula, and other forms of blood disease in this 
way, it is not always possible to exclude an infection, such as syphilis. 
The animal lymph can be controlled in its manufacture and produced 
with all scientific precautions. Animal lymph and human lymph do 
not differ in the power to confer immunity against variola. The 
animal lymph should be obtained from the healthy animal in the 
vesicular stage of the eruption ; this is the fourth or fifth day of 
cowpox. It is preserved by mixing it with three or four times its 
bulk of glycerin. It may be put up for use on quills or ivory slips 
in a dry state or in small capillary tubes in the liquid condition. 
The so-called vaccine pulp, made up of the contents of the vesicle 
and its epidermal covering, and preserved in glycerin, is not used in 
this country. 

Age at which to Vaccinate. — Every infant and child should be 
vaccinated. There is no contraindication except some acute or 
chronic illness. Even the hemorrhagic diathesis is no contraindica- 
tion. Vaccination is best done between the fourth and the sixth 
month, before teething has begun (Zimmerman). In an emergency, 
such as the presence of an epidemic of smallpox, the newly born 
infant may be vaccinated. 

Mode of Vaccination. — Boys are vaccinated on the left arm ; girls, 
for esthetic reasons, may be vaccinated on the thigh or calf of the 
leg instead. The outer surface of the arm, at about the insertion of 
the deltoid in the humerus, is usually selected. The skin is carefully 
cleansed with soap and water, washed with alcohol, and dried. 
With a clean sewing-needle the skin is scarified three or four times 
in one direction, and at right angles to the first scarifications. We 
should not cause bleeding, but only expose a raw surface. The 
scarified area should be about one-eighth of an inch square. The 
lymph is now rubbed on the scarified area. If quills are used, the 
vaccine on the quill is moistened with a drop of distilled water 
before inoculation. Scarifying large areas is likely to cause exces- 
sively large pustules, with subsequent severe inflammatory reaction. 
On the other hand, a small area of scarification may give a very large 
pustule. In other words, the size of the vaccine pustule does not 
always depend upon the size of the area of scarification. A mixed 
infection will give a severe reaction with a very small area of scari- 
fication. 

Lymph to Use. — Either the liquid or the dry lymph may be used. 



VACCINATION. 279 

Both are reliable if recently prepared. If the lymph is not fresh, or 
there is carelessness in its use, the vaccination will be a failure. 

Course of the Vaccination. — The great majority of vaccinations 
are very uniform in history. There is an incubation period, during 
which the wound heals. There are absolutely no symptoms. This 
period usually lasts three days, sometimes only two, and may be 
prolonged to four or six days. After this period there is the erup- 
tive stage, ushered in by the formation of flat rose-red papules 
at the points of scarification. The papules are either oval or 
irregularly long. On the fifth day a vesicle appears in the centre 
of the papule and spreads to the periphery. On the sixth day 
the vesicle takes up the whole papule, has a pearly lustre at the 
surface, and presents a central umbilication (Jenner^s vesicles). 
The seventh day is the day of efflorescence ; the vesicle is filled and 
tense with lymph, has a rose-red areola and a hypersemic zone out- 
side this areola ; there are itching and tension. On the eighth day 
the contents of the vesicle become slightly cloudy. On the ninth 
day the suppuration is pronounced, and on the tenth day the sup- 
puration, swelling, and inflammatory reaction are at their height. At 
the end of the tenth day there is a retrogression of all the symptoms. 
The vaccine pustule becomes less angry looking and the inflamma- 
tory reaction subsides. A crust forms which may become dry, 
hard, and fall ofF, leaving a scar beneath. This takes, as a rule, from 
ten to fourteen days. 

Fever in some cases begins on the fifth day after vaccination. 
It may be slight and reach its height between the eighth and the 
tenth day. There may at this time be slight digestive disturbances, 
such as vomiting or greenish movements. 

The areola around the vaccine pustule may spread so as to 
involve most of the upper part of the arm, or the inflammatory 
reaction may spread over the entire arm, and sometimes over the 
back. There may be enlargement of the lymph-nodes in the axillae. 
These lymph-nodes may suppurate. If there has been no mixed 
infection, they retrograde with the pustule. 

Complications. — Complications occur according to Sobel in 14 
per cent, of vaccinations, and are the result of traumatism of the 
pustule, mixed infection (that is, the presence of impurities, such 
as streptococci or staphylococci in the lymph), lack of cleanliness at 
the time of maturation of the pustule, and retention of pus in a dress- 
ing. The most common complication is an exceedingly severe reaction, 
with an extensive necrosis of tissue. This may affect the fasciae or 
muscular layers, causing large loss of tissue. Among the rarer com- 
plications of vaccination is a true septic infection. In these cases 
fhere is a history of mismanagement of the pustule, such as trauma- 
tism or the compression of the arm by a bandage. Infection which 
manifests itself in a remittent febrile curve occurs. In one case 
which came under my notice a few pus-corpuscles appeared in the 



280 THE SPECIFIC INFECTIOUS DISEASES. 

urine, the elbow-joint and other joints became painful and swollen, 
and suppuration in the joints resulted. These cases are fatal. 
There is a true osteomyelitis of the heads of the bones, with forma- 
tion of pus in the joints. In other cases the child may by scratch- 
ing inoculate itself elsewhere, either on the arms or even lips and 
eyelids ; the latter condition has come to my notice. It forms a 
very painful and severe complication. Erysipelas may set in early 
or late in the history of the vaccination. It may spread down the 
arm and forearm on the trunk and may endanger the life of the 
patient. In other cases there may be suppuration of lymph-nodes. 
In susceptible subjects a rebellious eczema may appear as a direct 
sequence of the vaccination. Among the complications may be 
mentioned axillary adenitis, hemorrhage into the pock (trauma), 
exuberant granulations, and keloid of the scar. Roseman found 
that the dry points contain more bacteria than glycerinized vaccine. 
All vaccine contains pus-organisms. He thinks that properly 
prepared glycerin lymph is to be preferred to dry points. The 
same investigator examined a large number of samples of commer- 
cial vaccine and failed to find tetanus germs in them. It seems 
more likely that carelessness in dressing or handling, the pernicious 
use of shields, or faulty technique in performing the operation has 
been the means of introducing tetanus-spores, rather than that these 
should be present in the vaccine virus. 

Generalized Vaccinia. — This is a general eruption of vaccine pus- 
tules, which in rare cases appears from the third to the seventh day 
over the Avhole trunk and extremities. It is really a generalized 
cowpox, similar to the generalized eruption in the exanthemata. 
D'Espine and Jeandin describe cases in which there can be no doubt 
of the absence of infection of the surface by the nails or otherwise. 
The prognosis in these cases is good ; there are no severe symp- 
toms, and the fever is slight. 

The management of a normal case of vaccination is important. 
We should protect the vesicle from traumatism by means of some 
simple contrivance, such as a shield. If the areola is angry looking 
and the redness and swelling severe, we may paint it once a day with 
compound tincture of benzoin. This is very soothing and protects 
the surface from friction. If complications occur, they should be 
treated on surgical principles. Above all, there should be no reten- 
tion of pus by any form of dressing. Dressings which seal the 
vaccine pustule hermetically from the air cause retention, and are 
therefore dangerous. Sepsis as described above is not the result of 
vaccination, but of subsequent mismanagement. 

Vaccination Eruptions. — The eruptions which follow vaccination 
or occur while the pustule is still in course of development are of 
interest. Sobel has made an exhaustive study of these eruptions. 
2 per cent, of the vaccinations are followed by more or less gen- 



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TYPHOID FEVER. 281 

eralized eruptions. They appear while the local site of the vacci- 
nation is open or as late as eight weeks after the primary inoculation, 
but most often between the ninth and the fourteenth day after 
inoculation. They have no relation to the size or severity of the 
local pustule, which may be normal. Among the types of eruptions 
are the erythematous, urticarial, papular, vesicular, pustular, mor- 
billiform, bullous, pemphigoid, and scarlatiniform. Auto-inoculation 
by scratching generally occurs an inch or tw^o from the original site, 
but it may occur elsewhere, as on the eyelid or conjunctiva. The 
most common type of generalized eruption is undoubtedly the 
urticarial in its various forms. These include wheals, papules, 
bullae, and vesicopapules. The morbilliform are easily differentiated 
by the absence of fever and coryza and other signs of measles. The 
scarlatinal forms cause great uneasiness and elevation of temperature. 
These cases should be observed for urinary complications and subse- 
quent desquamation, in order to exclude scarlet fever. Among the 
rarer types are the ecthymatous eruptions. 

Re vaccination. — Va.ccination should be repeated after the lapse 
of ten years, and every five years thereafter. During an epidemic, 
every one who has not been revaccinated should be vaccinated. 
Immunity to variola diminishes as we reach the termination of the 
first decade after the first vaccination. If the revaccination runs a 
typical course identical with that of the original vaccination, immu- 
nity is generally lasting. 



OTHER SPECIFIC INFECTIOUS DISEASES, 
VI. TYPHOID FEVER. 

(Abdominal Typhus ; Ikofyphus.) 

Occurrence. — Of 84 cases of typhoid fever treated by the 
author, 38 were of the male and 46 of the female sex. The ages 
were as follows : 1 was of eighteen months, 4 were three years, 9 
were four years, 41 were between the fifth and the tenth year, and 
the remaining cases ranged up to the fourteenth year. Thus 16 
per cent, occurred before the fifth year, and fully 50 per cent, from 
the fifth to the tenth year. 

Typhoid Fever and Pregnancy. — According to Etienne, quoted by 
Morse, the foetus in utero is born prematurely in 70 per cent, of the 
cases of typhoid fever in the mother. The causes of the abortion 
are much the same as those which obtain in pregnant women suffer- 
ing from any infectious disease. The high temperature, the toxins 
in the circulation of the mother, and the death of the foetus, all con- 
tribute to cause miscarriage. Of 12 abortions, 9 were stillbirths, 2 
lived four and 1 five days.. 



282 THE SPECIFIC INFECTIOUS DISEASES 

Foetal Typhoid. — There are two sets of cases which prove that 
typhoid fever can be transmitted from the mother to the foetus : 
First, those in which the mother, having been infected with typhoid 
fever, expels a foetus which may have lived some hours after birth 
and in whose organs the typhoid bacillus has been found, such as 
the cases of P. Ernst, Giglio, Lynch, and others. The second set 
of cases are those in which the blood and fluids of the foetus give 
the Widal reaction with bacillosis. Such is the case of Foster and 
Ballantyne. The mother of this foetus died from typhoid fever 
shortly after delivery. The stomach contents and the serum of the 
peritoneal cavity gave a Widal reaction. The bacillus was found in 
the kidney, spleen, and intestinal contents, but not in the blood. 

Griffith's case was that of an infant apparently healthy, though 
jaundiced, at birth. When seven weeks old the blood of this infant 
gave the agglutination reaction. It is possible that in this case the 
agglutination reaction passed from the mother to the foetus during 
the pregnancy without causing typhoid fever in the foetus. Thus, 
the presence of the agglutination reaction is no proof of typhoid 
fever, as it may be transmitted through the placenta, and the foetus 
thus escape typhoid fever (Ballantyne). 

The anatomical changes found in the foetus aifected by typhoid 
fever are not identical with those seen in the adult. This is due to 
the fact that the infection of the foetus is hsematogenous, which 
explains the high ftietal mortality. The spleen is sometimes though 
not always enlarged. The changes in the gut are not characteristic, 
being confined to a few enlarged follicles. The liver may be 
enlarged, and the kidney may show hemorrhages. 

Infantile Typhoid. — It has recently been contended that typhoid 
fever is rare in the infant or the child under tAvo years of age. 
With the improved methods of laboratory diagnosis of typhoid fever 
we may shortly be in a position to determine the relative fre- 
quency of the disease in the newborn and the young infant. Typhoid 
fever certainly occurs under the age of t^vo years. As Crozer 
Griffith has pointed out, we should think of the possibility of its 
presence in every case of continued remittent fever of the nursling 
not to be explained on other grounds. Of 331 cases, 9 under two 
years of age were diagnosed by Henoch as typhoid fever. Among 
others who report cases are Ollivier, Noyes, Northrup, and Bell. I 
have seen only 2 cases under two years. Blackader, in a recent 
series of 100 cases, met 4 under two years of age. Gerhardt reports 
a case in an infant twenty-five days old, and Blumer 1 in an infant 
five days old. These cases may be regarded as either congenital or 
post-natal typhoid. 

Morbid Anatomy. — It has been stated that when the foetus 
in utero is aifected with typhoid fever the process is in the 
nature of a hsematogenous infection, and that there are few if any 
characteristic anatomical changes. In young infants and children 



TYPHOID FEVER 283 

the changes in the gut so characteristic of adult cases are not always 
seen in their full development. The solitary follicles and Peyer's 
patches are enlarged, but ulcerations are seen only here and there, 
and seldom lead to perforation (Monti). On the other hand, in 
older children the changes in the gut closely resemble those of the 
adult, as has been shown by Henoch. The mesenteric lymph-nodes, 
especially those in the vicinity of the ileocsecal valve, are enlarged. 
The remaining changes resemble those seen in the adult subject. 

Symptoms. — The invasion of the disease in young children is 
rarely with a chill. More frequently there are indefinite chilly sen- 
sations and mild general malaise. There are headache, pains in the 
limbs, vertigo, and in many cases vomiting. The symptoms of the 
period of invasion are so very indefinite in infants and very young 
children that cases sometimes escape diagnosis. 

In other cases, after a few days of malaise the cerebral symptoms 
become marked. The headache is augmented by delirium at night, 
especially in older children, and stupor is present. In younger chil- 
dren the period of invasion may simulate a pneumonia. In fact, 
these cases begin as pneumonia, and it is only on careful considera- 
tion of the clinical symptoms — the predominance in a few cases 
of cerebral symptoms or the enlarged spleen, and the presence of 
roseola later on, with the elevation of temperature — that we are led to 
think of typhoid fever. In some of these pneumonic cases there are 
none of the characteristic features of typhoid. There is no roseola, 
no splenic enlargement, no epistaxis, but there may be diarrhoea. 
During an epidemic only the systematic examination of the blood 
(Widal) will reveal these cases. Such a case is the following : A 
child, five years of age, was admitted to my hospital service with an 
indefinite previous history. Temperature 104.6° F. (40.3° C), 
pulse 140, and respirations 30. There was apathy, also a broncho- 
pneumonia in the upper lobe of the left lung. This case gave a 
very positive Widal reaction early in the disease. The spleen 
became palpable four days after admission. In another case, of a 
child four years of age, signs of a lobar pneumonia of the upper 
lobe of the left lung were present without any roseola, enlarged 
spleen, diarrhoea, or abdominal symptoms. On the fifth day of the 
disease the Widal reaction became positive in a dilution of 1 : 50. 
This child died on the sixth day of the disease, with increasing signs 
of pneumonia and a positive Widal reaction of 1 : 350. Many of 
these cases of typhoid fever in older children become comatose after 
the first week. Such a case was recently admitted to my Avards. 
The onset was with headache and fever. There Avas no vomiting, 
epistaxis, or chill. The child became unconscious, with a tempera- 
ture of 106° F. (41.1° C), rigidity of the muscles of the neck, 
increased reflexes, ankle-clonus, Kernig's symptom, and enlarged 
spleen. This case gave a positive reaction to the Widal test, and 



284 



THE SPECIFIC INFECTIOUS DISEASES, 



lumbar puncture failed to reveal anything characteristic in the fluid 
withdrawn. 

The invasion is not characteristic in infants. In exceptional 
cases (Blackader) a convulsion is the first symptom noted. In some 
cases there may be a simple continued fever with diarrhoea, without 
other symptoms. In a case reported by Crozer Griffith the roseola 
and the enlarged spleen were present. 

The subsequent history of a case varies with the character of the 
infection. In the forms which have a slow, gradual onset the chil- 
dren remain for a time in good physical condition. During the first 
week the sensorium is clear, the tongue coated, and the face of 
good color ; the spleen may be readily palpable, the roseola appears, 
and there may be diarrhoea or constipation. In some cases the iliac 



Fig. 40. 


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Typhoid fever which began as a lobar pneumonia in a girl four years of age. Consolidation 
of the lower lobe of the left lung ; death on the tenth day of the disease. 

tenderness is marked ; in others absent. It may not be possible to 
determine the presence of ileocsecal tenderness in young children. 
The symptoms after the first week may be augmented by delirium at 
night ; in older children this delirium, which has much the same 
character as in the adult, is also present during the day. Children 
from five to seven years of age are more likely to have the quiet 
form of delirium, while older children are noisy and try to get out 
of bed. 

The course of pneumonic cases is noteworthy. Resolution is 
tardy in those cases which recover. To the symptoms of pneu- 
monia are added after a time those of typhoid fever — roseola and 
enlarged spleen. The temperature-curve is not characteristic, and 
resembles that of the sustained remittent type (Fig. 40). In some 
cases pleurisy may be present. 



TYPHOID FEVER. 285 

In the newly born infant to whom the fever has been conveyed in 
utero the picture of the disease is unlike that seen in older infants 
and children. The symptoms resemble those of sepsis of the new- 
born. Thus in the case published by Blumer the first symptom of 
the disease was an uncontrollable hemorrhage from the vagina. 
Before death this was supplemented by hemorrhages into the skin 
and from the gums. 

The cases of typhoid fever in infancy thus far recorded by 
Morse, Crozer Griffith, Blackader, and the author, may be divided 
into two classes : those in which there is a mild diarrhoea with dis- 
tention of the abdomen, roseola, and enlarged spleen ; and those 
which present cerebral symptoms. The latter develop coma, have 
a distended abdomen, rose spots, and enlarged spleen. In both 
forms there are severe and mild types. Cases in which the tempera- 
ture rarely rises above 104° F. (40° C.) recover, while those with a 
higher temperature may be fatal. 

Individual Symptoms. — Roseola. — In children, as in the adult, 
the roseolar papules are seldom absent. In some cases their number 
is large, while in others they are few and widely scattered over the 
surface. They may appear in successive crops, and reappear in a 
relapse. Occasionally the roseola is preceded by a diffuse erythema 
closely resembling the scarlet fever eruption. The roseola may, as 
in the adult, appear on the third, fifth, or tenth day, and may even 
be delayed until the end of the second week, after which it gradually 
fades, leaving a pigmented area. The eruption is sometimes so pro- 
fuse as to resemble the eruption of typhus. It may be profuse in 
cases in which the cerebral symptoms are very marked. I have 
seen typhoid fever with severe cerebral symptoms, but with an 
eruption very sparse or entirely absent at the height of the disease. 
In severe delirious cases, hemorrhagic areas appear on the bony 
prominences of the shoulders and extremities. Petechise are common. 
In protracted cases extensive purpuric areas appear on the abdomen. 
These hemorrhagic cases are not necessarily fatal. 

The ENLARGED SPLEEN is One of the most common physical 
signs. At the outset of the disease it is not always easy to pal- 
pate the spleen. This is especially true of younger children. The 
enlarged spleen is present not only in older children, but also in 
cases of foetal typhoid fever. I have seen the enlargement persist 
for weeks after convalescence. In one case the spleen could be 
distinctly felt below the border of the ribs for a long time after 
recovery. 

In some forms of relapse the spleen enlarges after having dimin- 
ished to the normal size. Cases in which the spleen remains 
enlarged a long time are likely to have slight rises of temperature 
of short duration. Typical relapses without enlargement of the 
spleen may occur. The fact that the spleen continues enlarged after 



286 



THE SPECIFIC INFECTIOUS DISEASES. 



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the temperature has become normal 
does Dot always indicate the ap- 
proach of a relapse. 

Temperature. — An elevation of 
temperature in young children is 
usually not observed during the first 
eight days. Children rarely complain 
of slight malaise, and a rise of a de- 
gree or even more above the normal 
may escape notice ; as a result, the 
impression is prevalent that the tem- 
perature during the first week does not 
follow the typical curve. The cases 
which I have observed sufficiently 
early, and which were not complicated 
with pneumonia, showed during the first 
week the gradual rise seen in the adult 
(Fig. 41). This gradual daily rise of 
temperature is also seen in relapses. On 
each day the temperature at its highest 
point is higher than on the previous 
day. After the first week the tem- 
perature is likely to show a remittent 
curve with a sustained maximum 
point. After the second week the 
temperature may remit, gradually fall- 
ing, or intermit ; frequently it re- 
mains high for weeks, with daily re- 
missions. By the end of the second 
week it reaches 104° to 105° F. (40° 
to 40.5° C.) at its highest. In the 
course of the third, fourth, and fifth 
weeks it may range a degree lower, 
with remissions to 101° F. (38.3° C), 
not reaching the normal. If the case 
is protracted, the temperature may per- 
sist into the sixth week, running up as 
high as 106° F. (41.1° C), falling fully 
five degrees twice daily. In one case 
the temperature did not become normal 
until the eighth week. Even at this 
late period there may be relapses. In 
many cases the temperature falls to the 
normal after six or seven weeks, or 
becomes subnormal, and then after an 
interval of a few days or a week rises 



TYPHOID FEVER. 



287 



and fluctuates a degree or more above the normal. This continues 
for a few days, the temperature remitting to the normal or near the 
normal. These post-typhoidal fluctuations are sometimes mistaken 
for relapses. They are rather to be attributed to inanition, or are 
the result of slight absorption from the gut. In a large number of 
cases the first sign of convalescence is a subnormal temperature. 
On the other hand, the temperature may be subnormal for a week 
or more and relapse follow (Fig. 42). 

It may be said that as a rule the first week of typhoid fever in 
children shows a gradual rise of temperature. The subsequent tem- 
perature is sustained, remitting two or more times daily. This curve 
may last one, two, or more weeks. In other words, there is no 
characteristic temperature-curve. In relapses the temperature rises 
gradually from day to day. Among the causes which may give rise 
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Typhoid fever of short duration in a boy six years of age. 

lobar pneumonia or a bronchopneumonia will cause a persistence 
of the high temperature, as will also other conditions, such as otitis. 

The inverted type of temperature-curve is described by Henoch. 
The morning temperature is higher than the evening, or there may 
be a rise at 3 A. m. or 6 A. m., a fall in the forenoon, with a rise 
again at noon, and a fall toward evening. Such a curve may be fol- 
lowed within a day or two by the usual fall in the morning and rise 
toward evening. These fluctuations occur at the height and at the 
decline of the disease. 

Hemorrhages from the bowel are not so common in children as 
in the adult. I have seen persistent hemorrhages in only 4 out of 
84 cases. In one case I have met post-typhoidal ulcerative colitis. 
The bowels may be constipated, normal, or diarrhoeal. The number 
of stools varies. In the majority of cases diarrhoea is absent. In 
some the temperature in convalescence may rise a degree or more for 
a day or two. In these cases there may be fecal accumulation due 
to incomplete evacuation of the gut. 



288 THE SPECIFIC INFECTIOUS DISEASES 

Pain. — Sensitiveness in the ileocsecal region is very difficult to 
determine in young children. In older children it is sometimes 
marked, and indicates ulcerative processes in that region or in the 
neighborhood of the appendix. 

Pain as a symptom in typhoid fever in the adult occurs in 
two-fifths of the cases observed by McCrae. In childhood it is 
not as common a symptom, inasmuch as young children are not apt 
to complain of pain. It is observed, however, though the exact 
percentage of cases cannot be stated, on account of the peculiarity 
of the subjects dealt with. In the adult abdominal pain in the 
course of typhoid fever is present in complicating pleurisy and pneu- 
monia ; or it may be due to a distended bladder, the ingestion of 
solid food, vomiting, faecal impaction, diarrhoea, appendicitis, peri- 
tonitis, cholecystitis, abscess of the liver, phlebitis of the abdominal 
veins, and hemorrhage. In childhood some of these conditions may 
be present, accompanied by abdominal pain. In the cases observed 
by the author cholecystitis, appendicitis, perforating ulcers, peri- 
tonitis, impaction of faeces, and vomiting could be fixed on as a 
causal factor in the production of the pain. Pain not due to per- 
foration, as a rule, is general in its location. It may be accom- 
panied by meteorism, or may be present with a retracted abdomen. 
I have seen it in some cases preceded by vomiting ; in other cases no 
such symptom was present. In childhood it is particularly noticea- 
ble that pain not due to perforation is unaccompanied by a rise of 
pulse, and certainly not by a rise of temperature. I have seen very 
severe abdominal pain, necessitating the administration of opiates, 
without the least disturbance of the pulse, respiration, or tempera- 
ture. This latter condition is apt to occur in nervous, hyper- 
sesthetic children. The pain due to perforation will be described 
elsewhere. I have seen one case where intense pain was caused by 
a distended gall-bladder with cholecystitis, the diagnosis being con- 
firmed at the operating table. In this case the pain was distinctly 
localized, and there was temperature due to the hepatic condition. 

Otitis is not uncommon. I have seen several cases. 

I have observed mastoiditis in 2 cases, 1 of which resulted fatally 
in the second week of the disease. 

I observed parotitis in only one case. 

The tongue of children with typhoid fever resembles that of the 
adult. It is at first coated, and is protruded in a tremulous man- 
ner ; subsequently the epithelium is thrown off and the papillae 
become prominent. In some cases the tongue resembles the so-called 
strawberry tongue seen in scarlet fever. At the height of the dis- 
ease it may become dry and fissured, and sordes may collect on the 
teeth. The lips become fissured and bleed easily. 

The nervous symptoms of older children resemble those of the 
^dult. With younger children sopor is the rule and deliriuni is 



TYPHOID FEVER. 289 

infrequent. Melancholia or depression occasionally is met with in 
convalescence, usually in girls of hysterical temperament. 

The Heart. — ^In a recent epidemic of typhoid many cases showed 
systolic apex -murmurs. These murmurs were loudest over the base, 
close to the sternum, or over the pulmonary orifice. Such murmurs 
are myocarditic. In one case there was a loud musical systolic 
murmur heard over the apex of the heart. It was also heard at the 
base of the heart. The murmur appeared early in the third week. 
There was also a pieuropericardial friction-sound. Post-mortem 
examination revealed myocarditis and pieuropericardial adhesion. 

The Lungs. — The occurrence of lobar or lobular pneumonia late 
in the course of typhoid is serious. At this time the patient's pow- 
ers of resistance are greatly diminished. Especially grave are the 
cases which show a sustained high temperature for two or three 
weeks, and then develop pneumonia. If with the pneumonia there 
are extensive hemorrhages under the skin at the situation of the 
bony prominences, the outlook is grave. In such a case I have seen 
a pneumonia involve the whole lobe of the lung in consolidation 
within a few hours. 

The Blood. — In children, as in the adult, the number of red blood- 
cells diminishes, and reaches the lowest point at the end of the febrile 
period. The haemoglobin also is diminished. The leucocytes are 
diminished from the outset until convalescence, but increase after 
it is established. In one of my cases their number fell to 3500, 
and then rose to 12,400. In a case complicated with extensive 
ulceration in the gut and bronchopneumonia they numbered 30,000. 
In fatal cases complicated with lobar pneumonia I have found them 
as low as 4500. According to Thayer, the polynuclear neutrophiles 
steadily diminish as convalescence approaches, while the mononu- 
clear lymphocytes and eosinophiles increase. With the establishment 
of convalescence blood conditions return to the normal. 

Relapses. — A relapse is a gradually ascending temperature-curve 
extending over a week or longer after the temperature has been 
normal for a time (Fig. 43). A relapse was noted in 7 of 46 cases 
of my last series. In all, it was mild and no serious results followed. 
On the other hand, a prolonged low febrile curve causes great emacia- 
tion in children. Undue importance has been attached to the condi- 
tion of the spleen in these cases. The percentage of relapses varies 
with the nature of the prevailing epidemic. Blackader records 15 
relapses in 100 cases, and Henoch 44 in 375 cases. Apparently 
relapses occur independently of the mode of treatment and diet. 

Complications and Sequelae. — Skin. — Subcutaneous abscesses 
may occur, and onychia is common. Erysipelas and parotitis are 
rare. CEdema may be confined to the scrotum, or during defer- 
vescence the whole surface of the body may be oedematous. In a 
case of scrotal oedema coming under my observation there were no 

19 



290 



THE SPECIFIC INFECTIOUS DISEASES. 





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casts or albumin in the urine ; 
the leucocytes were diminished. 
Henoch attributes oedema to car- 
diac weakness rather than to 
nephritis. 

Diphtheria is a very serious 
complication. I have observed 
it in 2 of 84 cases. 

The Lungs. — Bronchitis is a 
frequent complicatiou. In the 
later stages of the disease in 
yoimger children it is likely to 
develop into bronchopneumonia, 
especially in cases in which the 
course of the disease is pro- 
tracted. Pneumonia may occur. 
Gangrene of the lung is men- 
tioned by Henoch as a rare com- 
plication. 

Arthritis is uncommon. Usu- 
ally only one joint is affected. 
It occurs in the post-typhoidal 
period and runs a favorable 
course. 

Among the nervous symptoms 
which complicate or follow ty- 
phoid fever are aphasia, ambly- 
opia, ataxia of the lower extremi- 
ties, paralyses of various sets of 
muscles, double ptosis, and hemi- 
plegia. In hysterical children 
there may be a post-typhoidal 
melancholia. In others stupidity 
may persist for a time. Re- 
covery usually takes place in all 
forms of paralysis, aphasia, and 
melancholia. The paralyses are 
possibly due to a neuritis of toxic 
origin, as is the case with the 
other infectious diseases. Hemi- 
plegia occurs only as a result of 
embolism (Henoch). I have met 
cases of ataxia and marked melan- 
cholia. The children made an 
excellent recovery. In one case, 
a boy of four years, catalepsy 



TYPHOID FEVER. 291 

was present for a period of five weeks after the temperature had 
become normal. 

Perforation of the Intestine in Typhoid Fever. — The frequency 
of perforation of the intestine in children affected with typhoid 
fever, according to all available statistics, is 1.2 per cent, of all 
the cases. Of my own material of 95 cases there were 3 of perfora- 
tion, in 2 of which the diagnosis was confirmed by operation (2.1 
per cent.). In the adult subject the frequency is 1 to 2.5 per 
cent, of all cases. Therefore, in the severer forms of typhoid fever 
in children, perforation of the intestine is almost as frequent as in 
the adult. 

Time of Perfoeation.- — Most cases of perforation occur in 
the third week of the disease ; a few occur in the second week, and 
fewer still in the first week of the disease. Perforation may occur 
in the fourth or fifth week of the disease, or in the relapse. 

The symptoms of perforation in typhoid fever are insidious 
in their onset in some cases, and the disease may have existed for 
hours before the first symptom noted by most authors as marking 
the onset of the perforation — viz., pain — is pronounced. In other 
words, in 2 cases of perforation observed by the author, in which 
the diagnosis was confirmed by operation, the first symptom supposed 
to have marked the onset of the disease, six hours before operation, 
was pain. At this time there was marked peritonitis with fluid in 
the abdominal cavity, so that perforation must have existed hours 
before pain was noted. A study of the cases showed that one child 
(Case I.) complained of sudden vomiting twelve hours before the 
advent of the pain. Following the vomiting there was a sudden 
drop in the temperature. 

In one of my cases (Case II.) the temperature dropped on 
the thirty-second day from 102.4° to 97.6° F. ; the pulse rose to 
160. There was a slight chill, and some blood was passed in the 
movement, followed by a rise of temperature to 104.6° F. 

In the first case mentioned the onset was insidious. The day 
before marked symptoms set in the child was doing badly. She was 
somnolent, pale, and took very little nourishment. The pallor 
increased and vomiting was the first symptom to appear. With the 
vomiting there was rigidity and tenderness of the abdomen. Twelve 
hours after the onset the child suddenly complained of pain, which 
now became the leading symptom. The pain was most marked in 
the right iliac fossa ; the child was nauseated ; the rigidity and 
tenderness of the abdomen became more pronounced, and fluid was 
diagnosed in the peritoneal cavity. The temperature fell to 100|-° F., 
rising again to 105° F. The pulse rose gradually from 126 to 174. 
The child went into a condition of partial collapse just before 
operation. 

In another (Case III.), that of a boy of twelve, not operated 



292 THE SPECIFIC INFECTIOUS DISEASES, 

upon^ the first symptom appeared on the forty-third day of the 
disease. The temperature had been normal. From the fourth 
week on the boy was doing well, when suddenly, on the afternoon 
of the forty-third day, he complained of pain around the umbili- 
cus ; the abdomen became tender and tympanitic, the tempera- 
ture rose from 100.2° to 104° F., and the pulse rose from 
104 to 128. 

It can be seen from the description of these cases that in one the 
onset of the perforation was slow and insidious ; in the other two, 
brusque and quite apparent. In one case the onset was marked by 
slight vomiting. There was no distention of the abdomen in this 
case ; the pain was slight ; the child apparently had a simple dys- 
peptic attack. The immediate fall of the temperature, however, the 
change in the facies, the rise of the pulse, the rise of the temperature 
after the fall, directed our attention to some serious complication. 
In the second case the drop of the temperature, followed by a chill, 
with a subsequent rise of temperature, marked the advent of the 
perforation. 

In addition to the symptoms just noted as marking the onset of 
perforation in typhoid fever, there is an increase in the number of 
leucocytes. This was true of all the cases mentioned by the author. 
In one of his cases the leucocytes mounted from 6000 to 7000 to 
10,000 to the c.mm., and in another case to 13,000 to the c.mm. The 
liver dulness in two of the three cases disappeared gradually as the 
distention of the abdomen and the free gas in the abdominal cavity 
became more marked. In contrast with the distention of the 
abdomen in two cases, one presented retraction with rigidity of the 
abdomen, and in this case the peritonitis was most advanced at the 
time of operation. 

In addition to the symptoms just named, which are characteristic 
of intestinal perforation in typhoid fever in children, the respirations 
may become increased in frequency and may be of shallow depth, 
there is prostration, in some cases collapse, and a distinct change for 
the worse in the facies. The patients lie prone and resent interfer- 
ence. 

It may be stated that when peritonitis becomes more marked the 
leucocytes, after being increased, may be diminished. 

Of the general and local symptoms, therefore, of perforation 
complicating typhoid fever in children, the most valuable are the 
initial vomiting, or a chill followed by a drop in temperature, with 
accompanying abdominal pain, either localized or general, and a 
subsequent rise of the pulse, rise of the temperature, increase of 
leucocytes, increase of the local symptoms, such as pain, tenderness, 
tympanitis, rigidity of the abdomen, with a disappearance of liv^er 
dulness. In considering the symptoms seriatim the author is in- 
clined to lay most stress on the sudden appearance of a chill or of 



TYPHOID FEVER. 293 

vomiting in the course of typhoid fever in a patient who has not 
hitherto complained of these symptoms, accompanied by slight or 
marked abdominal pain with rigidity. The fall of temperature is 
followed by a rise, as hitherto noted ; the pain is slight at first, but 
may be sharp and abrupt in onset, increases subsequently, and 
reaches its highest intensity within twenty-four hours after the 
perforation. It is generally localized to the lower part of the abdo- 
men to the right side. It may be paroxysmal in character or 
constantly present. The distention of the abdomen, though present 
in most cases, may be absent, and in its place retraction may exist. 
The liver dulness disappears in most cases according to the amount 
of abdominal distention. 

Prognosis. — The prognosis in intestinal perforation complicating 
typhoid fever in children varies with the time which has elapsed 
from the onset of the perforation to the treatment. Fitz has shown 
that if left alone 5 per cent, of the cases in adults recover. In 
children we have no corresponding statistics, except that of my 3 
cases 1 recovered. This was an undoubted case of perforation in 
which the inflammation localized itself to the right iliac fossa. 
Elsberg has included my cases in statistics of 25 cases of typhoidal 
perforation in children with operative interference, in which the 
percentage of recovery was 64 per cent., as compared with 22.4 per 
cent, in the adult. The prognosis, therefore, in children, in mixed 
statistics, is apparently more favorable than in the adult. 

Duration of the Disease. — The duration of typhoid fever varies 
within wide limits. Henoch, in his tabulation of more than 200 
cases, shows that the longest duration was seventy days ; the short- 
est seven to nine days. In my own cases the duration varied 
widely, if the rises in temperature were taken into account. The 
average duration in the 95 cases was four weeks and three days. 
The shortest case lasted ten days, and the longest lasted eleven 
weeks. 

It might be stated in closing these statistics that the average age 
in my cases was somewhat over eight years. There were 5 cases 
among them of three years or younger, 1 case being twenty months ; 
another two years of age. 

Diagnosis. — Enough has been said to show that the diagnosis 
of typhoid fever in infancy and childhood is at times very difficult. 
With young children enteritis, pneumonia, meningitis, and even 
appendicitis may simulate typhoid fever in their onset. Cases 
which begin as a pneumonia are especially difficult of diagnosis. 
The cerebral forms of typhoid fever may closely resemble meningi- 
tis. The history is very important. The onset of typhoid fever is 
gradual, the cerebral symptoms increasing in intensity as the disease 
progresses. An enlarged spleen and a few roseolar papules will 
be of service in making a diagnosis, but, on the other hand, an enlarged 



294 THE SPECIFIC INFECTIOUS DISEASES. 

spleen is common to many conditions of infancy and childhood. In 
the most puzzling cases, such as those simulating enteritis of non- 
typhoidal nature, the roseola may at the outset be absent. 

In a doubtful case the Widal blood-test should be made daily to 
clear up the diagnosis. In many cases this reaction is the only clue 
to the condition. During the prevalence of an epidemic every case 
of pneumonia or doubtful meningitis or enteritis should be subjected 
to this test. 

The Widal agglutination reaction is of greater utility in making a 
positive diagnosis of typhoid fever in children than in adults. The 
fact that an enlarged spleen may be due to various causes, such as 
rickets, the occurrence of fevers of a remittent or continued type, 
possibly due to otitis, enteritis, pneumonia, and the prevalence of 
diarrhoea of all ^ kinds in infants and children, tend to make the 
Widal test of inestimable value. 

In a paper based on 84 of my cases of typhoid fever in infants 
and children, Gershel found the reaction positive in 81. Three 
hundred and twenty-nine examinations in all were made. Thirty- 
six were positive on the first test, and forty-five on repeated tests. 
The reaction appeared in 5 cases on the fifth day, in 3 cases on the 
sixth day, and in 3 on the seventh day. In other words, 13 per 
cent, of the tests were positive at the end of the seventh day, 63 per 
cent, on the fifteenth day, and 89 per cent, on the twenty -fifth day 
of the disease. The reaction was negative in only 3 cases which 
gave the clinical symptoms of typhoid fever. These figures corre- 
spond to those obtained by Blackader in a smaller number of cases. 
A negative reaction is of no significance as excluding typhoid fever, 
whereas a positive reaction is absolutely pathognomonic of the disease. 
Though 115 of my fever cases were examined by this test for the 
presence of typhoid fever, exclusive of the above 84 cases, the reaction 
was obtained in no case in which typhoid was not present. In a few 
cases the reaction was not obtained until the close of the disease, 
when the temperature had been normal for some days. In another 
case of a child of three years, the reaction was not obtained until a 
relapse had occurred. In the case of a boy of seven years the 
reaction was not obtained until the third week. It was not taken 
again until the onset of a relapse in the fifth week, and was negative. 
It subsequently became positive at the termination of the relapse. 
This proves that a negative test is of little significance in excluding 
the possibility of typhoid fever unless the examinations extend over 
a long period. The presence of the reaction in typhoid fevers 
which begin with a pneumonia is of interest. In one of these cases, 
fatal on the eighth day, in a child four years of age, the reaction w^as 
negative until the fourth day of the pneumonia. It became positive 
in an attenuation of 1 : 350 just before the exitus lethalis. 

The Ehrlich Diazo Reaction in the Urine. — Thirty-three cases were 



TYPHOID FEVER. 295 

examined with reference to this reaction. Tlie fifth day was the 
earliest day on which it was obtained. In the majority of cases the 
reaction was present from the seventh to the tenth day of the disease. 
The latest appearance was on the forty-seventh day from the outset 
of the disease. The reaction was absent in 15 per cent, of the cases. 
In all of the cases in which the Ehrlich reaction was obtained the 
Widal test was positive, and appeared in the first two weeks of the 
disease. The reaction may be present, as it was in one case, on the 
fifteenth day, and be absent on the next. The diazo reaction may 
appear before the Widal reaction, but in some cases the contrary is 
true. In conclusion, it may be said that in the presence of symp- 
toms and signs of typhoid fever the diazo reaction is an aid to diag- 
nosis, although not pathognomonic of the disease. 

Of the clinical signs pointing to typhoid fever, the character, 
of fever aids us but little. In the third week it may become 
intermittent, thus simulating malarial fever. In other cases the 
fever may be sustained with daily remissions until the fifth week. 
Typhoid fever with great ileocsecal tenderness and pain may closely 
simulate appendicitis. In a recent case published by Berg, ope- 
rated upon for appendicitis, the operation revealed that the patient 
was suffering from a perforation of the appendix due to an ulcer 
of typhoidal origin. A continued fever of longer duration than a 
week, a tremulous tongue, facies, a pulse below 120, an enlarged 
spleen, and a few roseolar spots, will aid in the diagnosis. The 
diagnosis of perforation of the gut is not always simple in chil- 
dren. In these subjects tympanites is not uncommon, aside from the 
presence of peritonitis. I have cited a case in which all signs 
pointed to perforation, and yet operation revealed nothing. The 
classical signs of perforation are those of collapse, a sudden fall of 
the temperature, and a rise of the pulse above its normal frequency, 
an increase of the leucocytes, and the presence of tympanites increas- 
ing until it causes a disappearance of the liver dulness. No one of 
these symptoms is absolutely pathognomonic. In many cases we shall 
be compelled to draw conclusions from the general history of the case. 

The diagnosis of typhoid fever must, therefore, be confirmed by 
the Widal reaction, except in a small percentage of cases. The 
presence of roseola, enlarged spleen, facies, trumulous tongue, diar- 
rhoea, and continued remittent fever are the clinical symptoms which 
should lead the physician to apply the test. 

The prognosis of typhoid fever in infancy and childhood is, as 
a rule, good. The mortality varies with the severity of the infection 
and the character of the epidemic. If the infection is severe, the 
complications will militate against recovery. Henoch, in 375 cases 
had a mortality of 14 per cent. ; Blackader, in 100 cases lost only 
1 ; Crozer Griffith had a mortality of 3 per cent. 



296 THE SPECIFIC INFECTIOUS DISEASES. 

It is commonly supposed, and some authors lay stress on the 
fact, that the mortality of typhoid fever in children is lower than in 
the adult, and therefore the prognosis is better. This simple state- 
ment does not give us any idea as to the true mortality of typhoid 
fever in children. Some authors place the mortality in this disease 
as low as 4 or 5 per cent. This may be true of some statistics in 
certain epidemics. In a series of 95 hospital cases of my own of 
typhoid fever in children, ranging from twenty months to thirteen 
years, the average mortality, extending over the three years, during 
which there were three distinct epidemics, was 9.4 per cent. This 
figure agrees with the percentage of mortality given by Henoch in 
350 cases of typhoid fever, and it would about express the average 
mortality of typhoid fever in children when epidemics of varying 
severity are taken into account. 

In this same material of 95 cases, the mortality in one year was 
only 4 per cent., and in another as high as 16 per cent. It will be 
seen from this that hospital cases, from which all statistics are 
drawn, show that the mortality of typhoid fever in infants and 
children is much the same as in the adult cases. In my 95 cases 
there were 9 deaths, distributed as follows : 

Below two years of age 2 cases no deaths 

Five years and below 14 " 2 " 

From sixth to tenth year 46 " 3 " 

From tenth to fifteenth year 33 " 4 " 

In this series of 95 cases of typhoid fever there were 15 per 
cent, of relapses. In this we include only those cases in which 
there was a true relapse — that is, an average normal temperature for 
at least eight days preceding the relapse. The average duration of 
the relapse was eleven days. The mortality in cases where there 
had been a relapse was nil. 

The treatment of mild cases of typhoid fever is purely symp- 
tomatic. There is little need for the administration of medicines. 
On the other hand, the severer cases are difficult to manage. This 
is especially true in the treatment of children, to whom it is not 
always possible to apply methods adopted with the adult. In cases 
in which delirium is present night and day bromides in large doses 
are efficacious. With older children they may prove useless, and 
morphine may then be necessary to meet the exigencies of the case. 

In the vast majority of cases milk forms the basis of the 
diet. If there is progressive emaciation, one, two, or three raw eggs 
should be added to the milk daily. It is well in protracted cases not 
to wait too long for a complete drop of temperature before resorting 
to other foods than milk. This is especially true of cases extending 
over a period of seven or eight weeks, in which there is always a rise 



TYPHOID FEVER. 297 

of temperature of half a degree or a degree above the normal for a 
few days, with a drop again to the normal or subnormal. In these 
cases there is a form of inanition fever, post-typhoidal in nature. 
Solid food should not be withheld too long lest the emaciation become 
extreme. After the fifth week we may in most cases allow the patient 
gruels containing cereals. After the temperature has fallen to the 
normal and remained there for four or five days, it is safe to return 
gradually to a full diet. It is doubtful if relapses occur as a result 
of too early feeding if this method is followed. In comatose states 
resort may be had to forced feeding. 

Alcohol is not needed in mild cases. It is given in cases in which 
the pulse is weak and the temperature high. Delirium is no contra- 
indication to its use, as it is in other affections. 

The heart is stimulated by digitalis, strychnine, or camphor. If 
the heart has shown slight dilatation with a murmur developing in 
the course of the disease, the patient should not be allowed out of 
bed too soon for fear that unfavorable symptoms may result. 

The temperature is controlled by hydrotherapy. The patient 
is placed in a bath at 100° F. (37.7° C), and the temperature of the 
water gradually reduced to 85° F. (29.4° C). With older children 
the temperature may be lowered still further. Children do not bear 
the classical Brand bath treatment well. The plunge bath is given 
three or four times daily whenever the temperature is 103° F. 
(39.4° C.) or more. Should the child struggle very much against 
the administration of the bath, it is wiser to forego it and sub- 
stitute sponging. If the sponging is not followed by good reaction, 
the use of water should be abandoned. In exceptional cases of 
delirium a bath once or twice daily at 105° F. (40.5° C.) has a 
quieting effect. 

Hemorrhages from the bo\Yel are not frequent in children. They 
may occur early or late in the disease. In the latter case they must 
be differentiated from hemorrhage due to enterocolitis of a post- 
typhoidal character. In hemorrhage due to typhoidal ulcer an ice- 
bag is applied to the abdomen, and small doses of opium, preferably 
the deodorized tincture, are administered to control peristalsis. 
Ergot and digitalis are given internally in order to contract the 
bloodvessels if possible. Enemata should not be given. If the 
hemorrhage becomes excessive, it is proper to give hot saline enemata, 
and to infuse normal saline solution under the skin or into the 
veins. 

Enteritis of an ulcerative or pseudomembranous character occur- 
ring as a complication of typhoid fever is treated in the same manner 
as the primary affection. 

Perforation should be treated on surgical principles. As with 
adults, those perforations which occur late in the disease, when the 



298 MALARIAL FEVER. 

patient is in an exhausted and emaciated condition, give a less 
favorable prognosis than those which occur early. The surgical 
treatment will be more successful the sooner the diagnosis is estab- 
lished, for in those cases in which peritonitis has advanced to a 
marked degree the prognosis is fatal. The success of surgical 
treatment will also depend largely on the fact as to whether the 
perforation is single or multiple. In one of my cases it was demon- 
strated at operation that no less than three ulcers had perforated, 
and there were as many more on the point of perforation, so that 
in this case simple sewing up of the ulcerated parts could scarcely 
have succeeded in saving the patient, for in this very case a per- 
foration after operation caused the death of the patient. In such 
cases the treatment of multiple perforations is a problem for the 
surgeon. 

Constipation. — In most cases of typhoid fever an enema will re- 
move accumulated feces from the lower bowel. Enemata are not 
given unless indicated. If the bowel contents are streaked with 
blood, enemata should be discontinued. In cases in which there is 
a slight rise of temperature during convalescence without apparent 
cause, grains v (0.3) hydrarg. cum creta should be given. Tym- 
panites is treated as in the adult subject. The evacuations should 
be mixed with an equal volume of a solution of carbolic acid (1 : 20) 
as soon as passed. The hands of the nurse should be thoroughly 
cleansed after each movement. The patient's hands are cleansed 
daily, in order to avoid auto-infection. 



VII. MALARIAL FEVER. 

{Paludism ; Malaria; Intermittent Fever.) 

Malarial fever is an acute infectious disease due to the inocula- 
tion of the individual with the Plasmodium malarise. It is common 
in infants and young children, and is believed to occur in utero. 
Crandall has reported a case in which symptoms developed eighteen 
hours after birth, and in which the plasm odium was found in the 
blood of the infant. Those who, like Moncorvo of Brazil, have 
opportunities to observe malarial fever in young infants and children, 
find the greatest frequency under two years. The author has not 
met paludism as frequently in the nursing infant as in older chil- 
dren. The reason for this must lie in the fact that young infants 
are more protected from infection witb veils, etc., than older chil- 
dren. One attack does not confer immunity to subsequent attacks ; 
on the contrary, infants and children once the subject of paludal 
poisoning seem particularly liable to reinfection and relapses. 

The period of incubation varies from a few hours to weeks. In 
the tertian type it is believed to be from seveu to fourteen days. In 



MALARIAL FEVER 299 

one of my cases the first chill appeared eleven days after the patient 
had left the malarious district. 

Etiology. — The essential cause of malarial fever is the same in 
infants and children as in the adult. It is an inoculation fever, 
and is conveyed to the human subject by a certain species of mos- 
quito (Anopheles). The poison exists in the neighborhood of 
swamps and stagnant waters. 

The Parasite. — The plasmodium or protozoa of malaria circulates 
in the blood of infants and children, undergoing its cycle and sporu- 
lation in the same manner as in the adult. In one series of cases 
in infants and children that I studied, the tertian was the most 
prevalent form of parasite. These cases occurred in New York City 
and its vicinity. This has been the experience of other ^ew York 
City observers. One may assume that the blood will, as a rule, con- 
tain the parasite prevalent in a given locality. Several forms of 
parasites may exist in the blood of the same child, or there may 
be several generations of the same plasmodium. These may mature 
at different times, giving various types of fever in the same subject. 
In a tertian case, the fever may thus become quotidian, a second set 
of parasites causing a distinct chill and fever (paroxysm) on the 
day when the first generation is quiescent. We may have, as 
Mannaberg and others pointed out, simple and double tertians and 
quartans. But no combination of quartan parasites can simulate 
the simple tertian type. I have seen very few cases of quartan 
in children. They are uncommon in New York City, but I have 
seen preparations of the quartan type which were found in the blood 
of children in the Southern States. As in adults, tertian paroxysms 
may occur every day, caused by two sets of parasites which mature 
at about the same time daily, or one set matures at a different hour 
than the set of the following day. In such a case paroxysms would 
occur at the same hour only every other day. Many children have 
a distinct severe paroxysm only every other day, but on the inter- 
vening day a careful examination will detect a very low fever. This 
is probably due to a set of parasites which mature without produc- 
ing marked chill or fever (abortive). 

The Blood. — In recent tertian I have found young spores in 
abundance in the blood a few hours after the chill. In some speci- 
mens the spores were free. Between paroxysms in tertian cases the 
blood contains colorless oval plasmodia — the fully developed body — 
leucocytes having rods and pigment-granules and rarely, small round 
forms with flagellse (Koplik). In stained specimens (methyl-blue) 
young native forms are found in all stages up to fully developed 
protozoa. The red blood-cell containing the parasite is distinctly 
enlarged. I have found in the stained specimen as in the unstained 
ones, the sporula in free groups, bodies with flagellse, and erythro- 



300 THE SPECIFIC INFECTIOUS DISEASES. 

cytes with stained granules. The half-moons are also found in 
chronic cases. The blood contains free granules, and peculiar 
shrunken, brassy-colored, red blood-cells. Monti found the specific 
gravity of the blood to be increased. 

Morbid Anatomy. — Post-mortem examinations in cases of ma- 
larial fever in infants and children are exceedingly rare. Oppor- 
tunity may be afforded when death occurs as the result of accident 
or of some other disease. Monti states that in fatal cases the spleen 
is enlarged; the capsule is tense, and in places shows rupture. The 
pulp is dark red owing to pigment deposit (melanin). Old spleens 
show a disappearance of melanin and a deposit of yellow ochre 
pigment along the trabeculse. In chronic cases the connective 
tissue is increased, the liver is enlarged, and there is atrophy of 
the liver-cells. The parasites are found in the blood. The endo- 
thelium of the bloodvessels contains yellow and brown pigment. 
In exceptional cases there are melanin deposits. In acute cases the 
bone-marrow is the seat of melanin deposit ; later this disappears, 
and the marrow is found to be yellow and fatty. The brain cortex 
in severe cases shows pigment deposit ; sometimes there are throm- 
boses and hemorrhages. 

Symptoms. — Children living in malarious districts do not 
always manifest malarial poisoning by having paroxysms of chills 
and fever. The disease is masked under the form of a progressive 
ansemia, with accompanying enlargement of the spleen. These 
patients develop symptoms in from a few days to a few weeks after 
leaving the malarious region. The period of incubation is thus dis- 
tinctly indicated. 

The onset of a paroxysm is usually marked by the appearance 
of chills. In young infants a distinct chill is not always present. 
They become cold and blue at a certain time each day. In older 
children the paroxysm is indicated by headache and a feeling of 
lassitude, which comes on at a certain time each day, or by a 
distinct chill. In exceptional cases eclampsia or vomiting may 
usher in a paroxysm. In other cases there is no eclampsia, but 
the hands become cold, there is a feeling of faintness, and the 
child complains of being ill. Meanwhile there is a rise of tempera- 
ture, during which there are muscular tremors of the extremities 
and a peculiar upward rolling of the eyes, indicating an impending 
convulsive seizure. The chill may occur during sleep. In one 
case the mother noticed that the child (three years of age) became 
pale during sleep, the hands and extremities became cool, and the 
pulse rapid. The febrile movement following the chill may be very 
slight, scarcely half a degree above the normal. In such cases the 
chill is not marked or is scarcely noticeable. This occurs in double 
tertian, in which one paroxysm is abortive. In most cases the fever 
is very high at first — so high that it is characteristic. A tempera- 



MALARIAL FEVER. 301 

ture of 106.5° F. (41.3° C.) is not uncommon, and is well borne. 
As a rule, the fever has a distinctly intermittent type. The tem- 
perature may rise after the initial chili and remain high for days, and 
then fall to the normal. In the simple form the fever lasts from 
four to twelve hours, and is followed by a critical perspiration, 
during which the temperature rapidly falls to the normal. In some 
cases the children appear free from symptoms in the interval between 
the paroxysms. Others suffer from headaches and a feeling of las- 
situde, and in infants there are gastric and intestinal disturbances. 
In protracted cases a distinct anaemia develops, with progressive 
enlargement of the spleen. Neuralgia of the peripheral nerves has 
been noted in older children. 

During a paroxysm Monti noted polyuria, which persisted until 
the following day. 

The spleen enlarges rapidly, and in a short time may be felt as 
low down as the umbilicus. I have found the spleen markedly 
enlarged ; in one case the organ was not palpable below the ribs, 
although a slight enlargement could be detected on percussion. 

The liver may be enlarged in chronic cases. 

In subacute forms chills are not present, but there is an irregular 
febrile movement, with progressive anaemia and splenic enlargement. 

Repeated Attacks or Relapses. — Children, as well as adults, 
may have repeated attacks of malarial fever. As a rule, however, 
these so-called independent attacks in children are relapses, due 
either to inefficient treatment or to the development of a new series 
of parasites. Infants may have relapses. I have treated such 
cases until all anaemia and signs of active malarial poisoning had 
disappeared, and then administered arsenic for months, only to 
find a return of the symptoms after an interval of months. 

The diagnosis of malarial fever is based upon an examination 
of the blood. If a child suffers from pronounced anaemia, ma- 
laise, pains in the limbs, and enlarged spleen the blood should be 
carefully examined. Expert knowledge is always necessary for a 
definite diagnosis. It is surjmsing to note the large number of 
cases beginning with chills and presenting an intermittent fever 
curve and enlarged spleen, diagnosed as malarious, in which parasites 
cannot be detected in the blood. Many septic and inflammatory proc- 
esses in infants and children simulate malaria. Rachitis, syphilis, 
gastro-enteric catarrh, otitis, pneumonia, typhoid fever with relapses, 
have all been mistaken for malarial fever. The diagnosis rests on an 
examination of the blood in all cases in which chills and fever or any 
of the symptoms described coexist with enlargement of the spleen. 

Quinine should not be administered until the blood has been 
very carefully examined. In other words, malaria should be diag- 
nosed or excluded before resorting to this remedy, which was formerly 
much in vogue as a diagnostic test. Its use before diagnosis can 



302 THE SPECIFIC INFECTIOUS DISEASES. 

only result in uncertainty, since there are rises in temperature, not 
due to the paludism, which may be influenced by quinine. A very 
high temperature of an intermittent type, in connection with other 
physical signs, should cause the physician to consider the possibility 
of paludal poisoning. 

I have not seen cases of the pernicious type. They occur in the 
Southern States. 

Acker has recently published 2 cases of malarial fever in children, 
in which there were the initial cerebral symptoms of coma and con- 
vulsions. Coma in one case came on in paroxysms. In the interval 
the child was rational. The sestivo-autumnal parasite (pernicious) 
was found in the blood. 

The prognosis of malarial fever in New York City is very good. 
With proper treatment the patient should recover. I have never 
met a fatal case. They occur in districts in which the pernicious 
type of the disease is prevalent. 

Treatment. — If possible, the patient should be removed from 
the malarious district. The remedies employed in all cases are 
quinine and arsenic, or their derivatives. 

According to Golgi, quinine should be given before the par- 
oxysm, and also in the intervals. The action of the drug is exerted 
directly upon the plasmodium. At this time segmentation of the 
parasite takes place in the blood, and most of the young parasites 
are free in the plasma. They then respond most quickly to quinine. 
Large doses should be given to infants and children, in order that 
the infection may be destroyed quickly and completely. The solu- 
ble bisulphate and muriate are suitable preparations. To an infant 
under one year of age grains ij (0.1) are given in a dose, repeated 
three times a day, the last dose being given from three to five hours 
before a paroxysm. To children between two and five years of age 
grains iij to v (0.2 to 0.3) are given in the same manner. Some 
infants take quinine readily when it is suspended in powder form 
in milk or water ; others are given a piece of chocolate, and when 
the surface of the mouth is coated with the candy the drug is admin- 
istered. Euquinine is a preparation tasteless and ordorless, and is 
readily taken by children. The dose is the same as that of 
quinine. The syrup of yerba santa is also a good menstruum. In 
cases in which children cannot take quinine by mouth, Jacobi 
advises giving it per rectum, dissolving the drug in a solution of 
tartaric acid. I have never been forced to use subcutaneous injec- 
tions of quinine, as the pernicious form of malaria in which this 
mode of therapy is principally resorted to is not prevalent in New 
York City. 

Infants and children with chronic or subacute forms of malaria 
are likely to be constipated. Under these conditions I have found 
calomel more efficient in clearing the gut than castor oil. 

After the quinine treatment has been continued for some time 



INFLUENZA. 303 

the spleen will be observed to diminish in size and the paroxysms 
to disappear. If the anaemia persists, it is well, after diminishing 
the frequency of the dosage of quinine, to combine it with small 
doses of Fowler's solution. The arsenic must occasionally be tem- 
porarily discontinued, or the functions of the stomach will become 
deranged. Warburg's tincture does not seem to be very efficacious 
with children under five years of age, nor with older children, 
unless given in very large doses. Children do not develop cincho- 
nism as quickly as adults, and the quinine may therefore be con- 
tinued for a long time. Treatment should not be suspended until 
the spleen is no longer palpable and the anaemia has disappeared. 
Quinine should then be continued in small doses at regular intervals. 
The preparations of cinchona, such as cinchonidia, cinchonidin, 
chinidin, etc., are not reliable. The following is Baccelli's formula 
for the subcutaneous use of quinine in pernicious intermittent fever : 

Quinin. miiriat 15 grs. (1.0). 

Natrinm chlorat 1 gr. (0.06). 

Aq. destillat ... ^^^iiss (10.0). 



VIII. INFLUENZA. 

{La Grippe; Acute Catarrhal Fever.) 

Influenza is a specific infectious disease chiefly affecting the 
mucous membranes. It is highly contagious, although all indi- 
viduals exposed do not contract the disease. It occurs in the form 
of pandemics in which whole communities are aflected. This pan- 
demic form occurs less frequently in children than adults, and is of 
interest to the physician only when an epidemic prevails. The 
endemic form of influenza affects children more frequently than 
adults, and is the form which will be described, although in its 
symptoms it closely resembles the epidemic form. The endemic 
form may occur at any season of the year. In large cities influenza 
is always present (endemic), and appears to be more prevalent after 
rapid changes from lower to higher temperatures. Rapid fluctua- 
tions in the humidity of the atmosphere in winter also favor the 
development of the germs of this disease. In New York City, 
midwinter and spring are the seasons when outbreaks of this affec- 
tion occur. 

Age. — Influenza may affect the newly born infant. A case of 
this kind is reported by Townsend in the Transactions of the Ameri- 
can Pediatric Society. The disease is most frequent between the 
ages of six months and five years. The younger the child, the more 
severe the affection. 

Mode of Infection. — Individuals are infected by coming into 
contact with others suffering with the disease. The germ is con- 
tained in the sputum and the nasal secretions ; therefore poorly 



304 THE SPECIFIC INFECTIOUS DISEASES. 

ventilated rooms and public conveyances favor the transmission of 
the disease. Parents may transmit it to their children in the act 
of kissing, and wet-nurses who have la grippe are likely to infect 
the infant at the breast. 

Etiology. — The epidemic form of influenza has been studied by 
Pfeiifer and Kitasato. Pfeiifer isolated a bacillus from the bronchial 
mucous membrane, trachea, and lungs. This bacillus, which is now 
believed to be the essential cause of epidemic influenza, is exceed- 
ingly small, and two or three times as long as it is broad. It has 
rounded extremities, occurs in pairs and chains, does not stain by 
Gram's method, and in influenza, pneumonia, and encephalitis is 
found in enormous numbers in the lungs. It is called the Bacillus 
influenzae. It is still an open question whether it occurs in the 
blood. Although this bacillus has been found in sporadic cases of 
endemic influenza, competent observers, Luzzato among the latest, 
have found that in a large number of endemic cases of influenza 
the Pfeiifer bacillus is absent. In its place is found the Frankel 
diplococcus. This is thought to be the essential cause of an im- 
portant group of cases of endemic and sporadic influenza in chil- 
dren — the so-called pneumococcus grippe. Predisposing elements 
in the etiology of endemic influenza are exposure to cold and a 
diuiinution of the strength of the individual. One attack does not 
protect the individual from subsequent attacks. 

Incubation. — Influenza is believed to have an incubation period 
of from twelve hours to three days. Endemic influenza occurs fre- 
quently in large cities and at times local epidemics of the disease 
are seen. 

Morbid Anatomy. — Inasmuch as influenza is rarely fatal, the 
pathological anatomy is imperfectly formulated. In fatal cases a 
general inflammatory condition of the mucous membrane of the 
nasal passages, and of the larynx and trachea, is found. The sur- 
face of the lining membrane of the bronchi is reddened, covered 
with mucopus, and the membrane itself is infiltrated with small 
round cells. There may be a diffuse inflammation of the smaller 
bronchi, with peribronchitis and inflammatory reaction. Areas of 
bronchopneumonia or lobar pneumonia are found in the lungs. 
The heart is dilated and the seat of myocarditis. There may be 
endocarditis and the kidneys may present an acute nephritis. The 
pleurae are inflamed, and there may be serous or serofibrinous 
pleurisy or empyema. 

Among the other lesions are those due to the complications, 
otitis, meningitis, inflammation of the gastro-intestinal tract, and 
cerebrospinal meningitis. 

Symptoms. — It has been customary to divide the symptoma- 
tology of endemic influenza as it occurs in children into clinical 
forms. According to my experience, there is no sharp dividing- 



INFLUENZA. 



305 



line between the various forms of endemic influenza as seen in 
children. The gastro-intestinal, nervous, and pneumonic forms are 
frequently present in the same patient. Endemic grippe as it occurs 
in children in New York City will be described, the epidemic or 
pandemic form being ignored. 

The most frequent form is the catarrhal of an acute and 
even subacute type. The infant or child may at the outset have 
a chill. Most frequently there is vomiting, and also fever, and 
pains in the head and limbs. There is a coryza, and in many 
cases a croupy, barking cough. The eyes are injected, the face is 
red and flushed, and the child presents an appearance resembling 
that of the first stage of measles. The mucous membrane of the 
throat is deeply injected and the tonsils inflamed and enlarged. 
The temperature is elevated ; in fact, at the outset it is as high in 
this disease as in malarial fever, 106.5° F. (41.3° C). The cough 
is sometimes incessant. The irritation in the throat is extreme, and 
vomiting after the coughing paroxysm 
may lead the physician to believe that 
he is dealing with whooping-cough. In 
young infants these symptoms may last 
for a day or two, during which the move- 
ments may become green and even diar- 
rhceal. This diarrhoea is sometimes so 
severe as to be a prominent feature of 
the disease. The prostration both in 
infants and children is marked. After 
two or three days the catarrhal condition 
of the upper air-passages subsides, and 
the patient develops symptoms of an 
acute bronchitis of a severe type. These 
forms of grippal bronchitis have at the 
outset a high febrile curve (Fig. 44), and 
a fever persisting for days. The bron- 
chitis affects the smallest bronchi. There 
may develop a bronchopneumonia in 
small areas. In other cases the bron- 
chitis passes suddenly into a pneumonia 
without a preceding chill. The pneu- 
monia of la grippe may be lobular or 
lobar in type. In the vast majority of 
cases the pneumonia is of the pneumococcus variety. Especially 
severe are the cases of grippe which are ushered in with a chill, high 
fever, and cerebral symptoms, such as sopor, delirium, and rigidity of 
the neck muscles. In many of these cases examination of the chest 
reveals pneumonia. These cases are not so common among infants 
as among older children. Cases in which there is a cerebrospinal in- 
20 







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DAY OF 
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Endemic influenza with bronchitis 
in an infant seven months of age. 



306 



THE SPECIFIC INFECTIOUS DISEASES. 



fection in no way differ from cases of cerebrospinal meningitis due to 
the meningococcus or the pneumococcus. The endemic grippal 
forms of cerebrospinal meningitis may be caused by the influenza 
bacillus (Sanger) or the pneumococcus. The child at first complains 
of fatigue, and has a tendency to sleepiness, cries out and starts in it^ 
sleep, and suffers from intense headache. After a time vomiting 















Fig. 


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Endemic influenza, lobar pneumonia of the lower lobe of the right lung. Child two and one- 
half years of age. 

with rigidity of the muscles of the neck sets in. These symptoms 
increase in intsnsity, sopor finally setting in with all the symptoms 
of a cerebrospinal meningitis. These cerebral cases are rare. A 
common form of grippal attack is that in which all the symptoms 
of nasopharyngeal inflammation are present. There is also mild 
bronchitis of the larger tubes. The temperature may fall to the 



INFLUENZA. 307 

normal in the morning or toward noon, but toward evening it rises 
from one-half a degree to three degrees above the normal (Fig. 43). 
The child plays in the afebrile intervals. It may awake from sleep 
in a peevish, irritable mood, or may start in its sleep. These symp- 
toms may continue for a week or longer. In many of these cases 
there is serous or purulent otitis media, or there may even be a 
mastoid inflammation from the outset. In other cases the patient 
has an intermittent or remittent fever. The fever, if a continued 
one, has morning or evening remissions. Examination of the heart 
may reveal an acute endocarditis, although marked symptoms of 
cardiac involvement may be absent. 

Symptoms referable to the kidney have received little attention 
in text-books. In endemic grippe there is almost always a slight 
trace of albumin in the urine, which, as a rule, disappears at con- 
valescence. Occasionally, there is a true nephritis, with casts, 
decreased secretion, and blood. Such cases have been described by 
Freeman. Of grave import are the cases of nephritis in endemic 
grippe which at first show a trace of albumin and a few hyaline, 
epithelial, and blood-casts, with a very small (microscopic) amount 
of blood in the urine. The urine is normal in amount. The con- 
dition is revealed only by the microscope. CEdema is absent. The 
child is at first pale, but this pallor disappears later. The trace of 
albumin in the urine, how^ever, with a few casts and blood-cells, 
persists for months. These cases have been described as "cyclic" 
albuminuria. They are really nephritis of an insidious character 
following endemic grippe. 

I have seen cases of endemic grippe complicated Avith swelling 
of the parotid and submaxillary glands and of the lymph-nodes of 
the neck. 

The duration of endemic grippe is from two or three days to as 
many weeks. I have seen cases present a temperature-curve for 
three weeks, but have not met the cases of protracted duration, with 
or without fever, described by Filatow, and would regard such cases 
as peculiar to the country of that author. 

The prognosis of endemic grippe is favorable. If complications 
supervene, it varies with their nature. 

The diagnosis presents no difficulties. In some cases the ner- 
vous symptoms may cause the physician to suspect meningitis when 
pneumonia is present. A careful physical examination will dispel 
the doubt. Meningitis and pneumonia may be present in the same 
case. Otitis may supervene without the presence of marked symp- 
toms referable to the ear. An aural examination by an expert 
should be made in all cases in which fever persists and physical 
examination of the lungs and other organs fails to reveal abnormal 
conditions. 

The treatment of la grippe is simple. At the outset in the 



308 THE SPECIFIC INFECTIOUS DISEASES. 

milder cases small doses of quinine are administered, to control the 
headache, restlessness, and fever. For the angina small doses of 
ferric chloride are given to infants every one to three hours. In older 
children, the throat is, in addition, sprayed two or three times daily 
with salt solution or a solution of boric acid or listerine. The fever 
is treated by sponging ; packing or baths are rarely necessary. The 
bowels of infants are washed out with high enemata if diarrhoea 
sets in, and milk food is temporarily suspended. Pneumonia, if 
present, is treated as outlined in the section on that disease. Otitis 
should be treated by early incision of the drum-membrane, as even 
cases in which no pus, but only serum, is present are relieved by 
this procedure. With older children the use of phenacetin alone or 
in combination with monobromate of camphor is permissible if the 
headache and pains in the limbs are very troublesome. A grain 
of each may be given once or twice daily for a short time. The 
prostration is best combated by the use of strychnine 'alone or com- 
bined with caffeine. Whiskey is not well borne in these cases, since 
it is likely to cause gastro-intestinal symptoms. 



IX. GLANDULAR FEVER. 

{Pfeiffer.) 

Glandular fever is a form of infection which manifests itself by 
an enlargement of the lymph-nodes of the neck, with accompanying 
enlargement of the liver and spleen, and an initial period of fever. 
It occurs from the second to the eighth year of life. During an 
extensive epidemic J. P. West observed it in the nursing infant. 

The etiology is obscure. This disease is a species of infection 
or toxaemia. In some cases (West) there has been diarrhoea, in 
others constipation, and in most cases a slight injection of the naso- 
pharynx. It is possible that the infectious agent gains access to the 
lymph-channels through the gut or nasopharynx. This would 
account for the involvement of the mesenteric glands, as observed 
by PfeifFer, and for the infection of the nodes of the neck through 
the thoracic duct. 

Symptoms. — After slight malaise, or even without prodromata, 
children are attacked with fever, restlessness, headache, vomiting, 
and pains in the limbs. After a few hours of these premonitory 
symptoms, swelling of the cervical glands on one or both sides is 
noticed. These glandular swellings extend from beneath the 
body of the jaw along and beneath the upper third of the sterno- 
mastoid muscle. The lymph-nodes beneath the muscle are also 
affected. After one or two days these glands or nodes not only 
increase in size, but nodes at the back of the neck and in the supra- 
clavicular region are also affected. In the cases recorded by West 



MENINGITIS. 309 

the axillary and inguinal lymph-nodes were also involved. The 
temperature at first ranges from 102° to 104° F. (38.8° to 40° C), 
but in from twenty-four to forty-eight hours it may fall by crisis. 
There is a slight redness of the pharynx or the color of the mucous 
membrane may be normal. There is pain on deglutition, and there 
may be a slight cough, but no distinct pulmonary affection. In 
both Pfeiffer's and West's cases the liver and spleen were enlarged. 
In the cases of Starck, Rauchfuss, and Protussow these enlarge- 
ments were not always present. 

The lymph-nodes may enlarge to the size of a pigeon's egg. The 
redness of the pharynx is disproportionate to the enlargement of the 
nodes (Rauchfuss), so that it is hardly permissible to speak of an 
anginal lymphadenitis, as in scarlet fever. In both Starck's and 
West's cases there was enlargement of the nodes, which were not 
painful, but sensitive to pressure. The swelling of the carotid 
lymph-nodes began, as a rule, after a few hours, was in most cases 
first visible on the left side of the neck, and reached its height from 
the second to the fourth day. The glands on the opposite side of 
the neck then became affected. The swelling rarely continues uni- 
lateral. It is uniform, as thick as an index-finger (West), and is 
composed of several nodes. There is a stiffness of the neck and 
also a sensation of choking. Suppuration is absent. There is in 
all cases a tenderness of the abdomen about the umbilicus, which, in 
Pfeiffer's opinion, indicates an infection of the mesenteric nodes. 
West found the mesenteric nodes enlarged in 37 cases. 

Diagnosis. — The disease is readily differentiated from mumps. 
In some epidemics the submaxillary glands were involved, but never 
the parotid. The appearance of the swelling of the lymph-nodes 
first on one side, and then on the other side of the neck is character- 
istic, and should be differentiated from the glandular swellings occur- 
ring with grippal affections or pneumonia. Heubner has reported 
cases in which there was a complicating nephritis. 

Duration. — The fever disappears after a few^ hours or may last 
two or three days. It may recur later. The gandular swellings, 
however, increase or persist nine to twenty-seven days, the average 
duration being sixteen days (West, Rauchfuss). 

Treatment. — As the affection has a tendency to spontaneous 
recovery, the treatment is purely symptomatic. 



X. MENINGITIS. 

Classification of the Diiferent Forms of Meningitis. — The 

simplest classification is that which divides meningitis into the 
primary and secondary forms. The primary form includes cerebro- 
spinal meningitis of the epidemic type, or cerebrospinal fever, as 



310 THE SPECIFIC INFECTIOUS DISEASES. 

also the sporadic forms of this disease, and, as a separate entity, the 
pneumococcus meningitis. In the secondary forms we have the 
tuberculous pneumococcus meningitis, the latter being secondary to 
pneumonia, endocarditis, or injury of the cranial bones. Third, 
there are the pyogenic forms of meningitis, due to staphylococci, 
streptococci, or secondary either to the disease of the cranium or 
local infections. Fourth, there are the forms of meningitis sec- 
ondary to typhoid fever, influenza, diphtheria, gonorrhoea, syphilis, 
anthrax, actinomycosis. Fifth, in a separate rubric there is the 
so-called serous meningitis, which is recognized as a secondary form 
of the disease, due probably to streptococci or pyogenic organisms. 
It will be seen that this classification recognizes both the sporadic 
and the epidemic forms of the cerebrospinal fever as the same dis- 
ease due to the same essential cause. 

Barlow and Gee divide simple meningitis in infants and children, 
as to locality, first, into the vertical form, which is a leptomenin- 
gitis, and affects the vertex of the cerebrum, sometimes spreading 
toward the base, and often involving the cord ; and in the second 
class they include the so-called postero-basic forms of meningitis, in 
which the exudate is confined principally to the posterior part of the 
base of the brain. 

In constructing- this section the author has utilized 110 cases 
of meningitis occurring in his hospital service. They were divided 
into the following groups : 68 were cases of the cerebrospinal form 
of meningitis of the epidemic type. Of the remaining cases, 35 
were tuberculous forms of meningitis, 1 case a so-called staphylo- 
coccus meningitis, 1 case a primary pneumococcus meningitis, 3 cases 
streptococcus meningitis, and in 2 cases a bacillus was found re- 
sembling the influenza bacillus in cultural characteristics. 

The author will first consider cerebrospinal meningitis of the epi- 
demic and sporadic type, and then will consider the so-called vertical 
meningitis and postero-basic meningitis of Barlow and Gee, serous 
meningitis, and finally tuberculous meningitis. 

Cerebrospinal Meningitis. 

( Cerebrospinal Fever ; Spotted Fever ; Petechial Fever ; Malignant Purpuric Fever.) 

Cerebrospinal meningitis is an acute infectious disease, the char- 
acteristic lesion of which is an exudative inflammation of the pia 
mater of the brain and spinal cord. It occurs in epidemics, but 
may occur sporadically. 

Etiology. — Cerebrospinal meningitis, both in its epidemic and 
sporadic forms, is due to an infection by the Diplococcus menin- 
gitis intracellularis of Leichtenstern, Weichselbaum, and Jager. 
This micro-organism is a diplococcus reminding one strongly in its 
form of the gonococcus. It is decolorized by the Gram stain. It 



CEREBROSPINAL MENINGITIS. 311 

is found not only in the body of the pus-cell — hence its name — but 
in the exudate also outside of the pus-cell. 

Though the epidemic form of cerebrospinal meningitis is caused 
in the vast majority of cases by this micro-organism, there is 
another group of cases of the cerebrospinal type which is caused by 
the Diplococcus pneumoniae. This latter class of cases has been 
described by Netter, Foa, and Bordoni-Uffreduzzi. These cases 
may occur epidemically also, but are generally seen in combination 
with lobar or broncho pneumonia, or as a complication of otitis 
media. The form of affection discussed in this section is rather the 
sporadic and epidemic type of cerebrospinal meningitis caused by 
the intracellular diplococcus above mentioned. In the epidemics 
of this disease so far observed, it is not unusual for several mem- 
bers of a family to be attacked. The rule, however, is the con- 
trary. The cases in an epidemic number several hundreds, the 
last epidemic in New York amounting to somewhat over 1000 
cases. 

The disease seems to have no marked tendency to spread. In 
large cities the epidemics occur in the spring of the year ; and, after 
the epidemic has run its course, sporadic cases are observed in the 
fall and winter months. 

Mode of Infection. — It has been a matter of great speculation 
as to how the infection is conveyed from person to person in this 
disease, if such does occur ; and also as to the manner in which the 
micro-organism — the intracellular diplococcus — gains access to the 
circulation. Cases are observed here and there, and I have seen 
two such cases in the last epidemic, in which the disease is compli- 
cated by pneumonia, the meningitis and the pneumonia both being 
due to the intracellular diplococcus. These cases, however, are 
exceptional. It has been supposed that the micro-organism gains 
access to the circulation through lymph-spaces in the mucous mem- 
brane of the nose and conjuctivse. 

I have published one case in which the Diplococcus intracellu- 
laris was found in the secretion of the conjunctiva in a child suffer- 
ing with the disease, in whom the meningitis had been preceded by 
a conjunctivitis. Wright has published a case in which the intra- 
cellular diplococcus was found in the nasal secretions of a person 
suffering from influenza symptoms, mild headache, fever, and con- 
stitutional disturbances, which might very well have been a mild 
form of cerebrospinal meningitis. A micrococcus, so-called Micro- 
coccus catarrhalis, is found in the normal secretions of the nose, and 
it has been mistaken time and again for the Diplococcus intra- 
cellularis. 

It has been intimated that the infection may gain access to the 
circulation through the respiratory organs. However these facts 
may be, they do not definitely establish how the infectious material 



312 THE SPECIFIC INFECTIOUS DISEASES. 

gains access to the circulation, or whether the disease is conveyed 
from person to person. 

Occurrence. — Cerebrospinal meningitis is distinctly a disease 
of young people. Rotch reports a case in an infant six days old. 
The youngest case of the epidemic type seen by me occurred in an 
infant ten weeks old. Of 111 cases reported by Councilman, 29 
occurred in infants and children. Of a series of 70 cases of cere- 
brospinal meningitis reported by me, 47 per cent, were under two 
years of age; the youngest was four months of age, and 61 per 
cent, of the cases were under four years of age. The oldest child 
in my hospital service was fourteen years of age. Thus the average 
age was two years. 

Morbid Anatomy. — In certain sporadic cases of cerebrospinal 
meningitis of the epidemic type the clinical symptoms may have 
been very marked, and yet post-mortem examination fails to reveal 
any gross mircoscopical lesions of the brain and pia mater. They 
appear to be normal. Under the microscope, however, a slight 
infiltration of the pia with pus and fibrin and a new growth of cells 
is seen. In other cases there is an extensive infiltration of the pia 
with serum, fibrin, and pus. The exudation is especially profuse at 
the base of the brain and on the posterior surface of the cord, more 
especially in those cases which will hereafter be described as postero- 
basic meningitis. The ventricles of the brain may be markedly 
distended with serum and even pus. Among the associated lesions 
found are subserous punctate hemorrhages of the endocardium ; 
ecchymoses and petechise of the skin, hyaline and granular degen- 
eration of muscle, multiple abscesses of the skin, suppuration of the 
joints, parenchymatous degeneration of the heart, liver and kidneys, 
and swelling of the lymph-nodes and spleen. In all the epidemic cases 
of the type referred to in this section the Diplococcus intracellularis 
is found in the exudate of the pia mater and cortex of the brain and 
in the fluid of the ventricles. 

Symptoms » — There are certain types of cerebrospinal menin- 
gitis which are seen both in the epidemic and sporadic forms of 
the disease. The malignant types are seen rather in the epidemic 
forms ; whereas the milder types are seen in the sporadic cases. 
Clinically, therefore, we may divide all cases of epidemic cerebro- 
spinal meningitis into three forms : The first form is the malig- 
nant type of the disease, in which the children, in previous good 
health, are attacked and die within twenty-four or thirty-six hours 
of the onset of the disease. 

The following case, one of the first of the epidemic of 1904, is a 
characteristic example of this type : An infant twelve months old, 
nursed at the breast; perfectly formed, large, healthy, bright child, 
never previously affected by any illness, nursing, and bowels normal. 
On the morning of the onset of the illness the child appeared drowsy 





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CEBEBR08PINAL MENINGITIS. 313 

and stupid, refused the breast, vomited once, but was not feverish. In 
the evening the infant was still drowsy and listless ; the temperature 
rose to 103° F. ; pulse 110 and weak. There w^as no peculiarity 
about the eyes, no stiffness of the muscles of the neck or body. 
Early on the morning of the next day the child aw-oke with a cry, 
and the mother discovered red spots on the cheeks ; the face w^as 
slightly swollen ; the eyes had a staring expression, and the child 
was apparently blind. A few hours later the entire face, hands, and 
body were covered with blotches of an ecchymotic character. The 
tissues of the extremities seemed to be hard to the touch and sw^ollen. 
The buttocks and body appeared as if the child had been beaten. 
Petechise and ecchymosis involved the whole surface of the body. 
At this time the temperature w^as 101° F., pulse very weak, scarcely 
perceptible at the wrist, the lips blue, the reflexes abolished. There 
was no rigidity of the muscles of the neck. There was no Kernig 
symptom. The pupils were uneven and did not react ; there w^as 
a slight conjunctivitis. The breathing was weak and catchy. 
Death supervened within a few hours. These cases are not unusual 
in epidemics, and here and there sporadic cases occur of this type." 

Another type of case is the more common form of the disease. 
A child in apparent health will suddenly complain of headache, 
fever, and begin to vomit. There may be a chill. The fever is 
generally high, the pulse rapid. The headache is very severe and 
is a constant leading symptom. There is also intense pain at the 
back of the neck, extending down the back. The child is irritable 
and restless, tossing about, intolerant of light and sound. Any in- 
terference and touch on examination of the surface of tlie body 
causes pain ; in other words, there is hypersesthesia. After a few 
hours rigidity of the muscles at the back of the neck appears, and 
this rigidity may increase to opisthotonos ; in some cases on the 
second day there may be repeated convulsions. When the disease 
is completely inaugurated the child lies in bed in a characteristic 
attitude, the lower extremities flexed, the arms flexed, the head 
slightly retracted. The children, for the most part, lie on the side. 
With the full onset of symptoms in some epidemics petechias appear 
with ecchymoses over the whole surface. These petechise vary in 
size from a pin-head to large blotches resembling hemorrhages due to 
traumatism. Ecchymoses are seen especially on the extensor sur- 
faces of the low^er extremities. The patients complain of constant 
headache, some are very restless, delirium sets in ; the delirium may 
be of a mild or suffering type. In some cases there is no sleep, the 
patients toss here and there in the bed, and complain of constant 
pain in the head. The bowels may be constipated ; in some cases 
there is diarrhoea. The urine may contain evidences of a nephritis. 
In other cases no such evidence is present. The amount of urine 
passed in some cases may be enormous ; in other words, there is 



314 THE SPECIFIC INFECTIOUS DISEASES 

polyuria. The spleen may be enlarged. The type of cases just 
described corresponds to the mass of cases seen in an epidemic. 

A third type of this disease is more puzzling in its character ; it 
affects infants and young children in apparent health. Infants and 
children are noticed to have a constant rise of temperature ; there 
may be vomiting ; there is restlessness ; if nursing, they refuse the 
breast. The fever after a few days takes an intermittent . course, 
mounting as high as 104° and 105° F. at certain times of the day ; 
falling to the normal or subnormal at others. In the intervals of 
freedom from temperature the children or infants will play, and 
when the temperature rises they complain of headache (if old enough), 
become drowsy and irritable, refuse nourishment, and develop symp- 
toms which point toward meningeal inflammation, such as the Ker- 
nig symptom, rigidity of the back of the neck. In these cases the 
typical symptoms of meningitis are not always present. Delirium 
may not be constant or may not extend over the twenty-four hours. 
The rigidity of the neck may not be very marked, especially in 
young infants, as has been intimated. The Kernig symptom in 
children, especially below two years of age, may not be evident. 
The most characteristic feature of these cases, it seems, is the pro- 
longed temperature of an intermittent type, closely resembling mala- 
rial fever. In fact, many of these cases have been mistaken for 
malaria. 

There is a fourth type of case, which will be described under 
the heading of Postero-basic Meningitis, which is observed not only 
sporadically, as has been remarked by Still, but also in epidemics. 

Individual Symptoms. — Mode of Onset. — In all the cases that 
I have had an opportunity to observe in my hospital and private 
practice, and in which the diagnosis was confirmed by lumbar punc- 
ture, the main characteristic of the disease was its sudden onset. In 
only a small percentage of cases was there a doubtful history of 
sudden onset. In this respect the disease differs markedly from 
other forms of meningitis, especially those of the tuberculous type, 
in which the invasion is slow and insidious. From a study of the 
symptoms the onset may simulate an attack of gastro enteritis in 
some children. 

Cerebral Symptoms. — If the fontanelle is not closed there is dis- 
tinct bulging or tenseness, even in the early stages of the disease, 
certainly before the fifth day. The patients suffer from delirium or 
coma, and in the milder cases headache is the principal symptom, 
and periods of consciousness alternate with those of stupor. Rigidity 
of the neck, either slight or marked, is present at one time or another 
in all cases, and opisthotonos is present in about 70 per cent, of the 
cases. 

According to Osier, neck rigidity or opisthotonos was not present 
in the adult form of primary pneumococcus meningitis. In one case, 



CEREBROSPINAL MENINGITIS. 315 

however, of my own, of primary pneumococcus meningitis in a child, 
neck rigidity was present. There is hypersesthesia of the surface, 
and the patients cry out if the bed is jarred or the skin touched. 
In some cases there are recurrent rigcrs and convulsions, either uni- 
lateral or general. There may be facial paralysis and hemiplegia 
in the early or the later stages of the disease. 

Reflexes. — In the majority of cases of epidemic cerebrospinal 
meningitis the patellar reflex is present in the early stages of the 
disease, but it may disappear in the rapidly fatal or moribund 
cases. The so-called tache cerebrale of Trousseau is obtained in all 
cases. 

Babinski Reflex. — Babinski, a French neurologist, described 
the extension of the great toe and separation of the other toes on 
irritation of the plantar surface of the foot as a characteristic sign of 
disease of the pyramidal tracts or the lateral columns of the cord. In 
epidemics of cerebrospinal meningitis this phenomena is obtained in 
only a small percentage of cases, in contradistinction to what is 
noted in the tuberculous form of meningitis, in which it is common, 
being obtained in 6 of 26 of my cases of tuberculous meningitis. 
The Babinski reflex is of very little value in children and infants 
below two years of age, for a phenomenon closely resembling it 
is obtained in perfectly normal individuals at this age. 

Kernig Symptom. — The Kernig symptom — that is, an inability 
to extend the leg on the thigh when the latter is flexed on the 
trunk — is obtained at one time or another in all cases of cerebro- 
spinal meningitis. In children below two years of age, however, 
this sign must be accepted with caution because of the natural ten- 
dency in infants and children of this age to contraction of the lower 
extremities, a variety of normal myotonia (Fig, 46). On the other 
hand, in cases of so-called cerebral symptoms complicating pneu- 
monia and typhoid fever, the Kernig phenomenon may also be 
apparent, so that, although it is present in all cases of meningitis, 
it is not pathognomonic of the disease. It may be absent in cases 
of the malignant type in which there are collapse symptoms. 

Hyperaesthesia. — In the majority of cases cerebrospinal menin- 
gitis, after the symptoms are fully established, the patients are irri- 
table, refuse to be comforted, start at the slightest sound, lie mostly 
on the side, the arms and lower extremities flexed, the body taking 
a crouching position. Any attempt to disturb the patients is met 
with resistance. The amount of hyperesthesia varies not only in 
the different epidemics, but in different types of the disease, but it is 
present in most cases, thus being in marked contrast to what is seen 
in the tuberculous form of meningitis, in which the children lie in a 
stuporous condition, do not notice their surroundings, cannot be 
roused, and are not as irritable as in the epidemic cerebrospinal 
form. 



316 THE SPECIFIC INFECTIOUS DISEASES 

MacEwen's Sign. — MacEwen has shown that in children, in 
various forms of meningitis, percussion of the skull over the an- 
terior horn of the ventricles will give a tympanitic note if the 
head is so held that the frontal or parietal bone may be percussed 
over the anterior horn of the ventricle. The patient is placed in 
the sitting posture, with the head inclined to one side, and per- 
cussion of the inferior frontal or parietal bone is carried out. 

The MacEwen sign is obtained in those cases of the cerebrospinal 
meningitis in which there is an accumulation of fluid in the ventri- 
cles, and was present in only 2 cases of 13 studied with a view to 

Fig. 46. 



Kernig symptom in a case of cerebrospinal meningitis of the epidemic type. Female, 

nine years of age. 

obtaining this sign. It is more common in the tuberculous forms 
of meningitis. 

Facial Paresis. — In epidemic cerebrospinal meningitis facial paral- 
ysis may occur in the very severe cases at the outset of the disease, 
especially if the base of the brain is involved. 

Paralysis. — There may be paralysis not only of the facial muscles, 
but of the extremities on one or the other side, either at the outset 
of the disease or toward the close. 

Eyes. — There may be an initial conjunctivitis, keratitis, strabismus, 
contraction, dilatation, or inequality of the pupils ; neuritis of 
varying grades of the disk ; atrophy, and finally purulent choroiditis. 
There is no appreciable impairment of vision in some cases. In a 
four- months-old baby paralysis of the orbital muscles of one side 



CEREBROSPINAL MENINGITIS. 317 

appeared early in the disease. A peculiar phenomenon has been 
observed by me and described by others referable to the pupils : If 
an attempt is made to bend the head forward as the patient lies in 
bed unconscious, the pupils will be observed to dilate (mydriasis). 

Contrary to the generally accepted opinion, we have found that 
expert examination of the fundus of the eye in cases of cerebro- 
spinal meningitis of the epidemic type revealed few changes in the 
optic pupilla in the majority of cases. In some cases there was 
dilatation of the veins, or congestion without neuritis. In only one 
case was there descending neuritis. This corresponds very closely 
to what Barlow and Gee found to be true both of the vertical and 
postero-basic forms of meningitis. In a group of 26 cases of 
meningitis of the tuberculous variety, however, examined by an 
expert ophthalmologist, some change was found in the fundus in 
fully 77 per cent, of the cases. This change consisted either of 
an optic neuritis or papillitis, or the presence of tubercles in the 
choroid. 

Blood. — The leucocyte count in cases of cerebrospinal meningitis 
of the epidemic type ranges from 20,000 to 55,000 to the cubic 
millimetre in 55 per cent, of the cases. There are cases, how- 
ever, with a low leucocyte count of 11,000 to 12,000 to the cubic 
millimetre. This corresponds very closely to what was found by 
Osier to be true of the adult cases. In tuberculous forms of men- 
ingitis, however, of infants and children, in 40 per cent, of the 
cases there is a leucocyte count of 20,000 to 25,000 to the cubic 
millimetre, and in 60 per cent, of the cases the leucocyte count is 
below 20,000 to the cubic millimetre. Rarely, however, does the 
leucocyte count exceed 24,000. 

In the fatal cases, in which the lumbar puncture may yield a fluid 
markedly purulent, the leucocyte count may mount from 35,000 to 
55,000 to the cubic millimetre. On the other hand, a fatal case with 
fluid obtained by lumbar puncture might show a leucocyte count not 
exceeding 23,200. 

Cases which have recovered may show in the course of the disease 
a leucocyte count of 14,000 to 28,000 to the cubic millimetre, and 
they may have mounted as high as 45,000. It cannot, therefore, be 
said that a prognosis as to recovery or fatal issue can be made from 
the leucocyte count alone in cerebrospinal meningitis. 

Pulse. — The pulse in cerebrospinal meningitis, as a rule, is rapid 
and irregular ; but there are periods in which the pulse is slow, 
sometimes 80 or even lower. This is not as common, however, as 
the rapid pulse. 

Respirations. — The respirations, as a rule, are shallow, increased 
in frequency, and irregular in rhythm. In a few cases there may 
be Cheyne-Stokes respiration. In other cases Cheyne-Stokes respira- 
tion is not seen in the whole course of the disease ; as the fatal 



318 



THE SPECIFIC INFECTIOUS DISEASES. 



issue approaches, the respirations may cease before the heart ceases 
to beat. Ill the terminal stages the respirations sometimes fall to 
10 a minute, and the pulse to 50, indicating the onset of general 
paralysis. 

Temperature. — There is no curve of temperature which is dis- 
tinctive of cerebrospinal meningitis. It may be said, however, that 
the temperature in many cases is of the intermittent variety, and 
for this reason these cases are frequently mistaken for malaria. In 
the intermittent type of temperature the remissions are very great, 
sometimes ranging eight degrees in twenty-four hours ; that is, a 
temperature which has been high will in a few hours fall to the 
subnormal to rise again. This is not uncommon and may extend 

Fig. 47. 




Cerebrospinal meningitis. Female infant, eiprht months of age ; unconscious on admission; 
fatal issue. (Meningococcus.) 



over weeks. On the other hand, the temperature may remain 
persistently high, especially in the rapidly fatal cases of the malig- 
nant type. 

In the chronic cases the temperature may fall to and continue 
within normal limits for days or even weeks. In some cases, after 
the temperature has remained normal for days or wrecks, there may 
be a so-called recrudescence of temperature of an intermittent type 
extending over a week or more. This does not preclude ultimate 
recovery. In one case in the recent epidemic the temperature con- 
tinued of the intermittent type, with the remissions mentioned above, 
for eight weeks, fell to the normal for a week, rose again, continued 
intermittent for a week, and finally fell to the normal and remained 
there. In this respect the temperature may even resemble typhoidaj 
curves of the third or fourth w^eek. 



CEREBROSPINAL MENINGITIS. 



319 



Spleen. — The spleen may be enlarged in some cases. 

Ear. — The ear may be the seat of otitis or mastoiditis. Deafness, 
especially where the base is involved, may supervene very early. 

The anterior fontanelle, as has been mentioned, in infants and 
children in whom the structure has not closed, may be tense or dis- 
tinctly bulging ; and in those cases in which there is considerable 
accumulation of fluid the posterior fontanelle may reopen. 

Skin. — In many of my cases there has not been that prevalence 
of skin rashes described by most authors. It has been only in the 
last epidemic of 1904 in which skin eruptions were prevalent. They 
included the roseola resembling that of typhoid fever. The roseola 
appears, as a rule, at the outset of the disease, and may recur in the 



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of the illness. Recovery. (Meningococcus.) 

course of the disease. Purpuric spots extending over the general 
surface are common at the outset, as well as ecchymoses, and these 
may disappear within a few days, leaving absolutely no trace of 
their presence ; or recurrent crops of ecchymoses and petechise may 
appear in the course of the disease. Herpes labialis varies in differ- 
ent epidemics as to its frequency, being absent in the majority of 
cases in some epidemics, and being frequent in others. Herpetic 
eruptions may occur elsewhere on the trunk or extremities. I have 
seen extensive herpes on the hand. One case has come to my 
notice in which the herpes were quite generally distributed over the 
trunk and extremities. 

Complications. — In some epidemics of cerebrospinal meningitis 
there are few complications. Those cases which recover do so with 
very little to .show that the nervous system in any of its extent has 
been severely compromised. The eyesight is not injured, nor is 
there subsequent hydrocephalus in any cases. In other words, the 



320 THE SPECIFIC INFECTIOUS DISEASES. 

recoveries when they occur are complete and satisfactory. This is 
especially true of small epidemic outbreaks occurring over the 
course of years. In the recent epidemic of 1904, however, the 
complications were more frequent ; joint complications were ob- 
served in 2 cases of a series of 30 ; blindness was not an uncom- 
mon complication, as also deafness. Recovery was incomplete, with 
hydrocephalus in several cases of a series of 30. Pneumonia was 
observed as a complication of cerebrospinal meningitis of the epi- 
demic type in 2 fatal cases. 

Sequelae. — Recovery may take place without compromise of 
any of the senses or functions of the patient. Both in young 
and older children hydrocephalus, either of a mild or severe type, 
may supervene in the course of the disease ; it may run a short 
course and the patient recover with a mild form of hydrocephalus, 
which in years gives rise to nervous symptoms, such as partial 
paresis or epileptic form of convulsions. Severe types of hydro- 
cephalus lead in many cases to permanent idiocy or imbecility, 
with or without paralysis. In some cases blindness or deafness 
results as a direct cause of meningitis. Arthritis, which some- 
times complicates the disease, has a tendency to get well and leave 
no marks of its presence. Many patients recover with so-called 
sensitive spines, or paresis of certain sets of muscles, which later 
in life becomes apparent. 

Optic neuritis or blindness occurring in the course of the disease 
very frequently retrogrades, and the patients, on recovery, bear no 
marks of any ocular lesion. 

Characteristics of the Fluid Obtained by Lumbar Punc- 
ture. — The fluid obtained by lumbar puncture in cases of menin- 
gitis, studied both as to cytology and bacteriology, is of par- 
ticular interest as regards the possibility of making a diagnosis. 
The cytology of the fluid obtained in cerebrospinal meningitis 
shows a preponderance of the polynuclear leucocytes. In a small 
percentage of cases the mononuclear cells, contrary to the general 
belief, may be prevailing elements, thus closely resembling what 
is seen in tuberculous meningitis. In chronic cases mononuclear 
leucocytes abound ; and in these cases, especially those of the basic 
type described by Still, the cytological picture resembles that of 
tuberculous meningitis. The fluid obtained by lumbar puncture 
in cerebrospinal meningitis may be quite clear, with scarcely any 
sediment, and may be markedly purulent, in this respect differing 
from the fluid obtained in tuberculous forms of meningitis, which 
is clear in at least 70 per cent, of the cases. 

Bacteria. — In the vast majority of cases of cerebrospinal men- 
ingitis the Diplococcus meningitidis intracellularis of Weischelbaum 
was found at one time or another, either in leucocytes or outside of 
the leucocytes. In the chronic cases, however, there are times in 



CEREBROSPINAL MENINGITIS. 321 

which the Diplococcus intracellularis is not found. This is espe- 
cially true of the posterior-basic cases. In those cases in which the 
diplococcus has not been found during life in the fluid obtained by 
lumbar ])uncture, it may be discovered post mortem in the fluid 
obtained from the ventricles of the brain. 

Course of the Disease. — The course of the disease after the 
symptoms are fully developed in typical cases has been indicated in 
the first part of this article. The patient lies unconscious, the head 
is retracted, and in some cases the back arched. The delirium is 
constant, and the patients complain of headache. The neck is rigid ; 
some patients complain also of pain in the course of the sciatic 
nerves. When disturbed they cry out with pain. There may be 
rigors, during which the patients become cyanosed and the heart 
feeble. The respirations are shallow and irregular. If the case lasts 
over a week the patients may refuse nourishment, and on this 
account marked emaciation sets in. In some cases the disease takes 
on an abortive type. After a period of headache, fever, vomiting, 
intervals of remission of all symptoms, including temperature, alter- 
nate with intervals in which the temperature runs an intermittent 
course, with a return of the headache, stupor, and uneasiness, convales- 
cence finally sets in, and the patients rapidly recover. Other cases 
result fatally in a few days. Some cases run a course of from eight 
to fifteen weeks, with the temperatures described, great emaciation, 
and finally make an incomplete recovery. Others attain a freedom 
from symptoms, but emaciation and paralysis persist, or even 
blindness and deafness, until an intercurrent affection ends the 
sufferings of the patient. As will be shown, there are few re- 
coveries in children below two years of age. In other cases re- 
covery takes place, but idiocy, hydrocephalus, blindness, or palsy 
may persist. 

Diagnosis. — Cerebrospinal meningitis must be differentiated 
from tuberculous meningitis, typhoid fever, and pneumonia with 
cerebral symptoms. 

It is distinguished from tuberculous meningitis by the sudden 
onset, its continued or intermittent higher febrile movement, the 
early onset and marked rigidity of the neck and opisthotonos, and, 
as has been intimated, the higher leucocytosis, and finally by the 
examination of the fluid obtained by lumbar puncture. Cerebrospinal 
meningitis is distinguished from typhoid fever by the fact that in the 
latter disease there is a leucopenia and a constant enlargement of 
the spleen with Widal reaction. On the other hand, there may be 
cases of typhoid fever in which the cerebral symptoms are very 
marked and in which a meningitis may be present, due to an inva- 
sion of the meninges of the brain and cord by the typhoid bacillus. 
In this set of cases the diagnosis will be very difficult without 
the aid of a lumbar puncture. The latter procedure being entirely 

21 



322 THE SPECIFIC INFECTIOUS DISEASES. 

innocent in its nature, should be made in order to exclude the 
severer affection of cerebrospinal meningitis. A pneumonia with 
cerebral symptoms will at the outset closely resemble a cerebrospinal 
meningitis, especially in very young children. Even if an exami- 
nation of the lungs reveals a pneumonia during an epidemic of 
meningitis, we cannot always exclude the latter disease without 
resort to a lumbar puncture, for cases of meningitis of the epidemic 
cerebrospinal type caused by the intracellular diplococcus are met in 
which pneumonia is present as a complication. On the other hand, 
pneumonia per se with cerebral symptoms does not, as a rule, give 
us the very marked rigidity, opisthotonos, petechise, intense cephal- 
algia, and Kernig symptom seen in cerebrospinal meningitis. I 
have, however, met isolated cases, both of pneumonia and typhoid 
fever with cerebral symptoms, in which a Kernig symptom was 
obtained, as well as the so-called tache cerebrale of Trousseau, 
although these cases are certainly exceptional ; in any doubtful case 
we should not hesitate, as has been said, to resort to lumbar punc- 
ture in order to clear up a given case. 

Prognosis. — The mortality of cerebrospinal meningitis varies 
largely with the severity of the infection and in different epidemics. 
In some epidemics the maliguant cases seem to predominate ; that 
is, those cases which die within a short time (from twenty-four 
hours to five days) after the onset of the disease. On the other 
hand, in small epidemics the mortality may not exceed 48 per 
cent. There are epidemics in which the mortality has risen as 
high as 90 per cent. Especially fatal are the posterior-basic cases 
and those attended by malignant features at the very outset of the 
disease. The prognosis, unfortunately, cannot be predicted in cere- 
brospinal meningitis, either from the nature of the fluid obtained by 
lumbar puncture, or from the condition of the blood as reflected in 
the leucocyte count, or the range of the temperature. We can only 
say that it is especially fatal the younger the patients. We have 
records, however, of cases of cerebrospinal meningitis occurring in 
infants of five months and one year of age, substantiated by culture 
and lumbar puncture, in which recovery occurred. 

The treatment of cerebrospinal meningitis is symptomatic. 
There have been many suggestions and variations of treatment in 
different epidemics ; but it must be said that the more we see of this 
disease, the more we are impressed with the fact that it is self-lim- 
ited, runs its course within a certain time, and can only be treated 
by palliative measures. 

The nutrition of the patient is a most important element in the 
management of these cases. In those cases in which the patient is 
comatose and refuses to take nourishment by the mouth, it is a dif- 
ficult problem to maintain the nutrition of the patient. In many 
cases nourishment must be given by the rectum, and in some must 



CEREBROSPINAL MENINGITIS. 323 

be introduced into the stomach by means of gavage. In the first 
case we frequently find that after nourishing the patient by the 
rectum for a few days this viscus becomes intolerant and very little 
nourishment is retained. Peptonized milk and somatose in the form 
of enemata are the most available forms of nourishment by the 
rectum. Gavag^e does not meet our ideals as to nourishment of the 
patient, because there is resistance to this procedure on the part 
of the unfortunate sufferers. Thus, each individual case will be a 
problem to the physician ; some patients take food with avidity, 
and in these cases milk and broths are the principal forms of 
nourishment given. 

The bowels of these patients are generally constipated, and from 
time to time a cathartic must be given ; the most preferable cathar- 
tics are the mercurials, calomel in dose of J to 2 grains, are given 
to clear the bowels. This may be repeated at intervals of forty- 
eight to seventy-two hours. Enemata do not seem to reach the 
majority of cases. The headache is very severe in a great number 
of cases, and no remedy that we know of completely relieves the 
symptom. Morphine given in moderate doses relieves some patients. 
In others this drug is not well borne, and the patients seem to 
become more stupid and the circulation weaker under its continued 
use. The author has tried the various drugs of the coal-tar series. 

Pyramidon in doses of 5 to 7 grains, given at intervals of three 
to four hours, seems to have relieved a certain percentage of cases. 
The head is shaved and the ice-cap applied. Even this procedure 
is not well borne by some patients, and they strongly protest against 
it. It seems to increase the pain. 

Following the English school, the iodide of sodium or potassium 
is given in liberal doses to limit the formation of exudate. It is 
impossible to say whether we can be successful by this means in 
influencing the inflammatory processes. However this may be, the 
author has given these patients liberal doses of iodide of sodium 
or potassium, preferably the former. Children under one year 
of age will bear 1 to 2 grains of the iodide of sodium three or 
four times daily w^ithout serious disturbance of the functions of the 
stomach. 

The delirium is treated with liberal doses of mixed bromides 
of sodium, potassium, and ammonia. In some cases chloral in 
moderate dose is added to this mixture, and is well borne by the 
patient. It does not depress the circulation. 

The irregularity of the heart which is present in a large number 
of cases does not call for any active treatment. Alcoholic stimu- 
lants should be avoided if possible, as there seems to be no indica- 
tion for their use. One of the principal modes of meeting restless- 
ness, the occasional high temperature, the rigors and accompanying 
cardiac weakness, is the systematic use of warm baths. The 



324 THE SPECIFIC INFECTIOUS DISEASES. 

patients are placed in a warm bath of a temperature of 105° to 
107° F. three times in the twenty-four hours. Care should be taken 
to lift the patient gently from the bed into the bath. Massage 
should not be performed as in the ordinary bath given in pneumonia, 
while the patient is in the bath, inasmuch as this friction irritates 
and excites the patient and seems to cause a great deal of pain. The 
duration of the bath should be from five to ten minutes. The time 
for giving it should be chosen when the temperature is on the rise, 
the irritability of the patient at this time being greatest. If the 
heart should become very weak, camphor is indicated ; if possible, 
by the stomach. If this is not feasible, camphor, in the form of 
camphorated oil, should be given subcutaneously. 

In cases in which there are symptoms of increasing exudate in 
the subarachnoid space, such as extreme rigidity, opisthotonos, coma, 
delirium, bulging fontanelle ; in young infants, chills with subse- 
quent rises of temperature, the operation of lumbar puncture should 
be performed. In those cases in which coma and delirium super- 
vene at the very outset of the disease, lumbar puncture may be per- 
formed within twenty-four to forty-eight hours of the onset of 
symptoms. I have frequently withdrawn in such cases 40 to 50 c.c. 
of a turbid fluid, with subsequent relief of delirium and headache. 
We should not hesitate after the first puncture to repeat the pro- 
cedure within forty-eight hours if symptoms either recur or remain 
stationary. In young infants and children especially repeated lum- 
bar puncture seems to be called for by the very fact that in these 
subjects the continued pressure and increase of fluid in the sub- 
arachnoid space and in the ventricles of the brain increases the 
tendency to dilatation of the ventricles, a serious complication which 
may lead to collapse symptoms, sudden death, or ultimate chronic 
hydrocephalus. In those cases in which at the outset of the disease 
the head retraction is very marked, the lumbar puncture is some- 
times unsatisfactory, inasmuch as little fluid is withdraAvn. In 
these cases the exudate at the base of the brain and the extreme 
retraction of the head may cut off the communication of the sub- 
arachnoid space and spinal cord with the ventricles of the brain. 
The canal of Majendie, through which this communication is sus- 
tained, is in these cases occluded. 

Lumbar puncture in a certain proportion of cases presents no 
relief to the patient ; nor can it be said, as yet, that lumbar punc- 
ture is curative. As has been intimated, it relieves symptoms of 
headache and delirium. It removes a certain amount of purulent 
exudate which is a menace to the vital structures of the brain and 
cord, and is thus a method of drainage rather than a curative 
measure. It may, in cases of sudden distention of the ventricles 
of the brain with fluid, avert death. 

The amount of fluid withdrawn at each puncture should be from 



ACUTE LEPTO-MENINGITIS. 325 

20 to 50 c.c, dependiDg greatly on the extent of pressure present, 
as indicated by the manner in which the fluid flows from the punc- 
ture cannula. If the fluid flows drop by drop, a small amount, 20 
to 30 C.C., is withdrawn. In some cases the fluid fairly spurts 
from the cannula, and in such cases 50 c.c. may be withdrawn, or 
even more. In other cases the exudate is so thick and purulent 
that it will not flow from the cannula except in large, thick drops 
at long intervals. We should not in these cases attach a syringe to 
the cannula and apply suction to the fluid, for in this way, it has 
been shown, hemorrhages may be caused in the spinal cord and in 
the pia of the brain. It need scarcely be mentioned here that every- 
thing in connection with the operation of lumber puncture should 
be carried out with due regard to asepsis. The puncture wound 
may be closed with collodium, or with a dry, sterile dressing 
of a few layers of gauze, held in place with plaster, and an anaes- 
thetic is not needed in children but may be administered to the 
adult. As might be supposed, a number of modifications on 
the procedure of simple lumbar puncture have been proposed. In 
the epidemics occurring in Portugal and Spain, lysol in 1 per cent, 
solution has been injected through the cannula into the subarachnoid 
space after a certain amount of cerebrospinal fluid had been with- 
drawn. One per cent., 2 per cent., and in New York as much as 
10 per cent, solutions have been injected, the solutions being at first 
carefully sterilized. It cannot be said that any success has followed 
injection of drugs, either lysol or preparations of mercury, in cere- 
brospinal meningitis. Their use has not been followed by a reduc- 
tion of mortality. Thus, there is no specific treatment of cerebro- 
spinal meningitis which will abort the disease, shorten its duration, 
or cure the patient. 

Acute Lepto-meningitis. 

( Vertical Meningitis. ) 

In this form of meningitis the vertex or superior surface of the 
brain is affected ; the region of the cerebrospinal foramen may 
escape, but not necessarily so, and in some cases the base also may 
be affected. 

Occurrence. — It is found in the newborn and children as a 
complication of sepsis, erysipelas, pneumonia, influenza, diseases of 
the ethmoid and mastoid bones, perforation of the bones of the 
skull, or suppurations elsewhere, such as retropharyngeal abscess. 

Etiology. — The essential cause is an invasion of the tissues of 
the meninges of the brain by streptococci, pneumococci, the intra- 
cellular diplococcus of Weichselbaum, the influenza and coli bacilli. 

These cases are sometimes difficult of diagnosis, because in many 
of them the classical symptoms of meningitis are absent. In the 



326 THE SPECIFIC INFECTIOUS DISEASES. 

early stages of the disease anatomically there is dryness and opacity 
of the pia hypersemia. Later, oedematous conditions of the pia 
supervene with the formation of lymph and fibrin along the sulci 
and in the tissue of the pia mater and on its surface. Later, the 
purulent exudate may extend over the surface of the brain, involv- 
ing not only the base of the brain, but also the spinal cord. In 
some cases the exudate does not penetrate the ventricles of the 
brain ; in others inflammation extends into the ventricles. In this 
form of meningitis there are complications either primary or second- 
ary, such as pneumonia, empyema, pericarditis. 

Symptoms. — The diagnosis is difficult. The symptoms are 
often latent. Retraction of the head is very often absent, and 
ocular symptoms are rarer ; in fact, the fundus in many cases is 
found to be normal. Vomiting is less frequent than in the basic 
forms of meningitis to be described, or in the cerebrospinal forms 
just described. Convulsions of a violent character may be present ; 
they may be repeated throughout the disease, and are associated in 
some cases with high temperature ; in other cases they are absent. 
These convulsions may be epileptiform. Clonic spasms may be local 
at first, but, as a rule, they become bilateral and general. There 
may be, as in meningitis, tonic spasms. The duration of the dis- 
ease is shorter than in posterior-basic meningitis, may last from one 
to two days to as many weeks, and in exceptional cases may become 
chronic. In many cases it is impossible, unless a lumbar puncture 
is made, to differentiate these cases from tubercular meningitis. Nor 
is it possible, if the exudate extends to the spinal cord and rigidity 
sets in, to differentiate a so-called vertical case from an ordinary 
cerebrospinal meningitis of the epidemic type unless a lumbar punc- 
ture is made. The differentiation, therefore, of these cases must 
depend on a continued observation of the case and the performance 
of lumbar puncture. 

Posterior-basic Meningitis. 

Posterior-basic meningitis is so called because the inflammation 
affects the posterior part of the base of the brain and the structures 
in this location, and rarely spreads to the vertex of the brain, at 
most only affecting the tips of the temporosphenoidal lobes, and in 
some cases extending forward to the optic commissure. These 
cases were first described by Gee and Barlow, in the Bartholomew 
Hospital Reports of 1878, and subsequently by Still in 1898. 

Occurrence. — The affection occurs in infants and children be- 
low the age of two years, and is rarely seen in older children. 
I have seen exceptional cases in children of three and five years 
of age. 

Etiology. — These cases, according to Still, are caused by a 



PLATE X. 




Posterior Basic Meningitis. (Gee, Ba^lo^A^ and Still.) 
Author's case. 



POSTEBIOR-BASIC MENINGITIS. 327 

diplococcus which is identical with the diplococcus of Weich- 
selbaum, Jager, and Leichtenstern, an intracellular diplococcus 
not staining with Gram's method. Although Still thought that 
these were only sporadic cases of the epidemic form of cerebro- 
spinal meningitis, it can now be said that they are seen very 
frequently and in large numbers in epidemics of cerebrospinal 
meningitis, and may occur sporadically. They are only specific, 
inasmuch as they are a form of cerebrospinal meningitis as it 
occurs in younger children and infants. These cases divide them- 
selves into those which are fatal after six weeks ; those which die 
after three or four months with hydrocephalus; and those which 
recover. In the first set of cases anatomically we find pus and 
lymph at the base of the brain and extending down the cord. In 
the second set of cases there is simply thickening of the pia and 
arachnoid, with adhesions between the cerebellum and medulla. 
The inflammation may spread down the cord to a varying degree, 
and upward along the lining membrane of the ventricles, and after- 
ward along the base as far as the optic commissure. In the chronic 
cases there may be adhesions of the meninges either in the anterior 
part of the base of the brain or even on the vertex, showing that 
this has been slightly involved. The adhesions at the base may 
unite the medulla and cerebellum and obliterate the foramen of 
Magendie or the fourth ventricle. This results in accumulation of 
'fluid in the ventricles with hydrocephalus. In some cases the ven- 
tricular fluid is clear ; in others it contains flakes of fibrin and pus. 

As has been shown, complications in this form are rare. Oc- 
casional arthritis is found. In some cases Still has found tuber- 
culous foci ; of the viscera, which he considers accidental. In 
other cases the middle ear may contain mucopurulent secretion, 
but no evidence of the extension of the ear disease to the brain or 
meninges. 

Symptoms. — The onset, as in cerebrospinal meningitis, is abrupt 
and has the same symptomatology. The most characteristic symptom 
clinically of these cases is the retraction of the head. This supervenes 
early and continues until death or recovery of the patient. Convul- 
sions, tonic or clonic, occur early in the disease, but are less frequent 
than in meningitis, involving the superior surface of the brain and 
cord. There are rigidity of the limbs and opisthotonos, and an increase 
and diminution of this rigidity, in the course of the disease, with 
tetanic contractures of the upper and lower extremities, as shown in 
the accompanying drawings. Vomiting is one of the first or early 
symptoms, and may occur throughout the disease. After the dis- 
ease has lasted some time the eyes have a fixed stare ; there may be 
strabismus or nystagmus ; the pupils are contracted, or later may 
be dilated. Optic neuritis is not common, though the patients may 
be blind. If the anterior fontanelle is still open, it bulges with the 



S28 THE SPECIFIC INFECTIOUS mSEASES. 

increasing hydrocephalus, and in some cases the posterior fontanelle, 
which may have been closed, is reopened, the sutures become widely 
separated, and the children finally lay unconscious and perform 
automatic movements with the facial muscles, mouth, and extremi- 
ties. The rigidity and retraction in some cases are extreme ; the 
opisthotonos is very marked at times ; at others the neck rigidity 
will relax, but on the least irritation, either of friction or otherwise, 
the opisthotonos and tetanic spasms recur. Recovery may take 
place with retrograde of most or all of these symptoms, or imper- 
fectly so with hydrocephalus. In some of these cases the tempera- 
ture curve at first is high, and after the disease has lasted some time 
it may drop to the normal and remain there, or rise a degree above 
the normal, at times thus simulating tuberculous meningitis ; or the 
temperature may be norma] for periods of weeks and then suddenly, 
without any apparent cause, show wide variations, with high tem- 
peratures during certain parts of the day and subnormal tempera- 
tures at others. Death may supervene suddenly without cause. 

The prognosis is very bad. There are few recoveries, and in 
an epidemic most of these children die or develop an incurable 
hydrocephalus. 

The treatment is directed toward the relief of the hydroceph- 
alus. As soon as this is established or evident, repeated lumbar 
puncture should be performed, in order to stay the increase of the 
fluid in the ventricles, and, if possible, effect a cure of the hydro- 
cephalus; this is not always possible. The treatment of the symp- 
toms are the same as that laid down for cerebrospinal meningitis. 

Meningitis Serosa (Quincke). 

{Acute Internal Hydrocephalus.) 

Meningitis serosa, or acute internal hydrocephalus, must not be 
confounded with tuberculous meningitis, which formerly was called 
acute internal hydrocephalus. Meningitis serosa was described in 
1893 by Quincke. Four years later Bonninghaus reported some of 
these cases, and since then a number have been described in the 
literature. 

Occurrence and Definition. — It is a comparatively rare disease, 
and occurs only between the ages of one and five years. It consists 
of a serous inflammation of the extra- and intra-cerebral pia mater, 
and as a consequence of this inflammation there is an inflammatory 
oedema in the subarachnoidal space, accompanied by acute internal 
hydrocephalus, or serous exudate in the ventricles of the brain. We 
have two forms of this condition : in one the brain and membranes 
are found to be the seat of inflammatory oedema, in which the exu- 
date in the ventricles is comparatively small in amount ; in the other, 
the more common form, there is a very large exudate in the ven- 




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MENINGITIS SEROSA. 329 

tricles, and the membranes of the brain and pia mater are but 
little affected. 

The etiology is not quite clear. Quincke insists that the condi- 
tion may occur idiopathically, in a manner similar to an idiopathic 
pleurisy. Later authors are inclined to regard serous meningitis, 
however, as an infectious process, due to the invasions of staphylo- 
cocci or streptococci, which are found in the ventricular fluid 
removed through lumbar puncture or post mortem. Some of these 
cases may follow a chronic hydrocephalus ; others may be traumatic 
or complicate an acute febrile disease, such as typhoid fever or 
pneumonia. 

The symptoms are not always marked, and it is not always 
possible to recognize the disease with certainty. The differential 
diagnosis from other forms of meningitis, such as the tuberculous 
form, is made with the greatest difficulty. The disease may begin 
with varying symptoms. The children are peevish and restless ; 
they refuse to take nourishment. There may be constipation, dis- 
turbances of the process of digestion, and finally vomiting, with 
continued emaciation. The temperature in all cases thus far observed 
is raised but little above the normal ; or, if raised to 103° F., rapidly 
falls again to normal. The pulse may be normal or slightly in- 
creased in rapidity. A constant symptom in children below fourteen 
months is that the head increases in circumference, the sutures are 
forced apart, and the anterior fontanelle becomes tense and bulging. 
The cerebral symptoms consist mostly of sopor, uneasiness, strabis- 
mus, and nystagmus. Sooner or later convulsions appear, involving 
most of the musculature or groups of muscles. In some cases an 
early optic neuritis has been observed. 

The course of the disease is a protracted one, inasmuch as the 
symptoms may extend over weeks or months, ending finally in death, 
preceded by an increasing cachexia. 

In those cases which have recovered, the circumference of the 
head has returned to its normal dimensions. 

Morbid Anatomy. — The most striking lesions found post mortem 
are a dilatation of the ventricles of the brain with an increased 
amount of intraventricular fluid, by which the surface of the brain 
is compressed and the convolutions flattened. The ependyma is 
swollen, thickened, and the surface granular. The choroid plexus 
is hypersemic. The membranes of the brain may be dull and more 
or less hypersemic. In some rare cases, at the base of the brain 
a circumscribed purulent meningitis has been described, which sup- 
ports the view that serous meningitis may follow a localized con- 
dition of this character. 

A characteristic of serous meningitis is the cloudy swelling with 
proliferation and desquamation of the cells of the ependyma, and 
cellular infiltration of the brain substance beneath the ependyma 



330 THE SPECIFIC INFECTIOUS DISEASES. 

with round cells, especially along the bloodvessels. In such cases 
there is really an ependymitis or meningitis ventricularis. 

The diagnosis of serous meningitis must be made from menin- 
gitis of other varieties, especially of the tuberculous or cerebrospinal 
type. The author is inclined to believe that during life a very 
careful exclusion of every possible infection is the first step toward 
the diagnosis. It is a well-known fact that forms of otitis media 
purulenta will cause cerebral symptoms and even an increase in the 
intraventricular fluid, and such otitis is apt to be overlooked, unless 
thought of at the time a diagnosis is made. The patient, therefore, 
would run greater danger from such an accident, and would lose a 
chance of recovery if the diagnosis of otitis or mastoid disease were 
too long delayed. 

Optic neuritis, which is present in most cases, may be present 
in forms of meningitis of the cerebrospinal type, although Beck puts 
much stress on this phenomenon. The author is inclined to believe 
that lumbar puncture will aid more in the diagnosis than any other 
procedure. The puncture fluid in cases of meningitis serosa thus 
far published contained no microorganisms, was of low specific 
gravity, generally 1.007, contained 1 to 1.5 per cent, of albumin, 
and very few if any cellular elements beyond those of a few blood- 
corpuscles. On the other hand, a tuberculous meningitis would give 
a puncture fluid which, though it might in a certain percentage of 
cases be devoid of microorganisms, would contain a number of mono- 
nuclear lymphocytes. In cerebrospinal meningitis the puncture 
fluid would contain microorganisms unless the meningitis was of a 
chronic variety, in which form the microorganisms might be absent. 
In cerebrospinal meningitis, however, a study of the puncture fluid 
would again aid us, inasmuch as it would show a preponderance of 
of the polynuclear leucocytes. 

XIII. MUMPS. 

(Epidemic Parotitis.) 

Mumps is an infectious and contagious disease of the parotid 
gland, at times involving the pther salivary glands as well as the 
testis or ovary. 

Etiology. — Parotitis is endemic in large cities, and frequently 
becomes epidemic in schools and institutions where large numbers 
of children are congregated. It is most common among children 
of school age, because they are more exposed to infection than 
children at an earlier or later period of life. Girls and boys are 
attacked with the same frequency. It may occur in the newly born 
infant. The author has seen a case in an infant three weeks of age. 

The essential cause of mumps is unknown. Laveran and Catlin 
describe micrococci which they found in the blood and in the glandu- 



MUMPS. 331 

lar lymph of the parotid and testis. These micrococci were arranged 
in twos and fours, did not stain by the Gram method, and were 
1 to 1.5 micromillimetres in diameter. Michaelis and Bein isolated 
an intracellular chain-forming diplococcus from Steno's duct. The 
theory thus far advanced is that these micro-organisms gain access 
to the parotid through the duct. The period of incubation, according 
to Killiet and Lombard, may vary from seven to twenty-six days. 

Morbid Anatomy. — As the disease is rarely if ever fatal, 
opportunities to determine the morbid conditions have been few. 
Virchow first described the condition of the gland as one of in- 
flammatory serous and cellular infiltration of the intra-acinous and 
peri-acinous connective tissue. The outcome is resolution ; indura- 
tion rarely remains. 

Symptoms. — There is a prodromal period, during which the 
patient is attacked with chilly sensations or a chill, and sometimes 

Fig. 49. 




Bilateral parotitis. 

with vomiting. There is pain in the region of the ear, and also a 
ringing in the ears and deafness. There is also a febrile move- 
ment, the temperature in some cases moanting to 104° F. (40° C). 
The temperature may be normal throughout the disease. There may 
be headache and loss of appetite. After these symptoms have lasted 
awhile, the face becomes swollen, as a rule on one side only (Fig. 49). 



332 



THE SPECIFIC INFECTIOUS DISEASES. 



This swelling gives the face au uneven contour, and is the charac- 
teristic symptom. In older children it causes a feeling of tenseness 
and pain on mastication. Sometimes patients are averse to opening 
the mouth on account of the pain. In young infants there is drool- 
ing. In the majority of cases, after the swelling has lasted three 
or four days and is subsiding, the opposite side becomes affected. 
In addition to the swelling of the parotid there is also intumescence 
of the lymph-nodes of the neck at the angle of the jaw and of the 
node on the parotid gland in front of the ear. Frequently the sub- 
maxillary glands are also swollen, giving the whole face a rounded 



Fig. 50. 




iParotitis involving the submaxillary glands, lateral view. Boy, four years of age. 

contour. In most cases the general condition of the patients is good 
and there is very little discomfort. Other cases have considerable 
pain and constitutional disturbance. In all my cases there was 
distinct angina and swelling of the tonsils. In a newly born baby 
there was swelling of the tissues underneath the jaw and about the 
larynx, with croupy breathing indicating oedema of the mucous 
membrane of the larynx. 

English authors have described cases in which the submaxillary 
glands alone were involved, the inflammation being strictly limited 
to the glands on both sides (Fig. 50). I have seen a few cases of 
this kind. 



MUMPS. 



333 



Complications. — The testes and epididymis in boys and the 
ovaries and glands of Bartholini in girls may become affected. There 
may be ardor urinse and a urethral discharge. These complications 
are not so common as the text-books declare. Hydrocele may 
occur with the orchitis. I have seen a case of this kind in a very 
young infant. The urine may show a trace of albumin, or in 
very rare cases there may be blood in the urine. Endocarditis, 
pericarditis, rheumatism, and osteomyelitis have been reported as 
complications, but the author has never met such cases. Parotitis 
complicating pneumonia has been observed in a boy of six years, 
and in another case otitis and parotitis were present at the same 
time. In rare cases the breasts and lachrymal glands are affected. 
Parotitis may be a complication of typhoid fever, measles, varicella, 
and influenza. 

Course. — The disease is at its height in from three to six days, 
and runs its course in from seven to fourteen days. Mild cases may 

Fig. 51. 




Angioma of the parotid simulating mumps. 



last only two days. Severe cases are rare. These present cerebral 
symptoms, and swelling of the tissues about the neck simulating 
angina Ludovici, with considerable dyspnoea. Cases of recurrent 
mumps, continuing for from four to six weeks, are recorded. When 
suppuration occurs, it is probably the result of some mixed infection. 



334 THE SPECIFIC INFECTIOUS DISEASES. 

The diagnosis is not difficult. Uncertainty as to whether the 
parotid is affected or not will be dispelled by drawing a line parallel 
with the lower border of the jaw ; the parotid swelling will be above 
the line and the lymph-nodes of the neck below it (Fig. 51). In 
swelling of the mastoid region the ear is raised from the skull, while 
in parotid swelling, even if it occur behind the ear, that organ 
remains in its normal position. The swelling of parotitis never fluc- 
tuates, but is elastic in character. 

The prognosis of mumps is good ; the majority of cases recover 
without complications. If the kidneys and endocardium and peri- 
cardium are affected, the prognosis will be influenced by the course of 
these affections. I have never known epidemic parotitis to result 
fatally. 

Treatment. — The patients are isolated and kept in bed as long 
as symptoms are present. The parotid is anointed twice daily with 
warm oil of hyoscyamus and covered with cotton. The bowels 
should be regulated with a saline cathartic. The diet should be 
assimilable. The affection cannot be controlled by means of drugs. 
Pain and fever are treated on general principles. 

XIV. PERTUSSIS CONVULSIVA. 

( Whooping-cough.) 

Pertussis is an acute specific infectious disease, caused by a micro- 
organism, probably of the influenza group. It is characterized in 
the majority of cases by a spasmodic cough accompanied by a so- 
called whoop. 

Pertussis is not only infectious, but it is also contagious. It is 
propagated through the atmosphere in schools and public places, the 
air of which is contaminated with the specific agent of the disease. 
The micro-organism is thought to exist in the sputum and the secre- 
tions of the nasal and air-passages of the patient. The disease is 
especially contagious at the height of the attack. There is reason 
to believe that the cough of the first or catarrhal stage is highly 
contagious. The sputum in the stage of decline is also, in my 
opinion, capable of conveying the disease to others, since it contains 
the specific micro-organism. 

Occurrence. — Pertussis prevails in all countries and climates. 
It is most frequent during the winter and spring months. It is 
always endemic in large cities, but, like scarlet fever, becomes at 
times so prevalent as to be epidemic. Pertussis is essentially a dis- 
ease of infancy and childhood, but the individual is not exempt at 
any age. It has been seen in the newly born infant. I have 
found the disease slightly more frequent in females than in males 
(1009 out of 1820 cases). Twxnty-two cases occurred in infants 
between one and two months of age. The majority of cases (1343) 
occurred between the sixth month and the fifth year. The disease 



PERTUSSIS CONVULSIVA. 335 

is most frequent between the first and the second year (404) ; 
next most frequent between the sixth and twelfth month. After 
the fifth year the frequency diminishes up to the tenth year, after 
which the disease is very infrequent. Not every one who is exposed 
contracts the disease. One attack does not necesarily confer im- 
munity, but cases of second attack are rare. It has been observed 
that pertussis, measles, and influenza frequently follow one another 
in epidemic form. 

Incubation. — The incubation period is variously placed at from 
two to fourteen days. 

Etiology and Bacteriology. — The essential cause of pertussis 
was believed by Deichler and KurloflP to be a protozoa-like body 
which they found in the sputum. Afanassjew and Szemetzchenko 
isolated a bacillus from the sputum. It occurred singly, in pairs 
or chains, and measured 0.6 to 2.2 micromillimetres in length. The 
more recent researches on the bacteriology of pertussis are those 
of Czapelewski, Hensel, and Koplik. Czapelewski and Hensel 
described in 1897 a non-motile '^pole bacterium^' or bacillus 
resembling the influenza bacillus. I at the same time described 
in the sputum a finely punctate, thin, minute bacillus, 0.8 to 1.7 
micromillimetres in length, resembling the influenza bacillus, and 
staining like that or like the diphtheria bacillus. This bacillus was 
found recently by Luzatto in cases occurring in an epidemic of per- 
tussis in the city of Graz. It is classified by him as belonging to 
the influenza group. Positive proof that this bacillus is the cause 
of pertussis is lacking, since the disease has not as yet been pro- 
duced experimentally. Evidence simply points toward a bacillus 
of the influenza group constantly found in the sputum. 

Morbid Anatomy. — Post-mortem examination reveals marked 
inflammation of the nasal passages, bronchopneumonia, and empyema 
or simple fibrinous or serous pleurisy. Emphysema as a result of 
rupture of the lung-tissues has been reported by Northrup, who 
describes the lungs of an infant seven months old as being studded 
with cavities measuring one-half a centimetre to two centimetres in 
diameter. The lungs looked like parchment filled with bubbles. 
Hemorrhages in the eye, ear, and brain are a feature of the morbid 
anatomy of fatal cases. 

Symptoms. — There is undoubtedly a period of incubation, but 
its length is undetermined, and it can only be said that, if the dis- 
ease is due to the invasion of a micro-organism, some time must 
elapse between the invasion and appearance of symptoms. After the 
appearance of the symptoms there are three stages^the catarrhal, 
the spasmodic, and the stage of decline. There is no sharp line 
of demarcation between these stages. 

Catarrhal Stage. — This stage in some children is characterized by 
a cough which is especially troublesome at night, and has sometimes 
a croupy character. The peculiar nature of the cough becomes ap- 



336 THE SPECIFIC INFECTIOUS DISEASES. 

parent when after a few days it becomes more troublesome instead 
of subsiding. After four or five days it may be accompanied by 
vomiting once or twice a day, especially if the paroxysm occurs 
after meals. Examination of the chest may fail to reveal bronchitis. 
This negative sign is of great value. As the case passes into the 
spasmodic stage it is noticed that the paroxysms of coughing last 
longer, and that the child becomes red in the face and expectorates 
a larger amount of mucus than in ordinary catarrhal conditions. 
This period of cough without a whoop may last five to twelve 
days. I have seen many cases in which the Avhoop was absent in 
the whole course of the affection. The child had what might be 
regarded as a severe spasmodic cough followed by vomiting. Fever 
is present as a rule only during the first few days. It may be re- 
mittent and slight. If bronchitis complicates this stage of the dis- 
ease, there may be a daily rise of one or more degrees in temperature. 
Usually toward the close of the catarrhal stage the incessant cough 
causes slight puffiness of the eyelids and slight oedema of the tissues 
of the face. 

The spasmodic stage is distinguished by the presence of the char- 
acteristic whoop. The cough becomes of a more pronounced spas- 
modic type. The child has distinct paroxysms, which begin with 
an inspiration, followed by several expulsive explosive coughs, after 
which there is a deep, long-drawn inspiration, which is characterized 
by a loud crowing called the whoop. After one paroxysm has 
ended, it may be followed by a number of similar ones. When a 
paroxysm is impending the face assumes an anxious expression, 
and the child runs to the nearest person or to some article of furni- 
ture and grasps it with both hands. The paroxysm is sometimes 
so severe that the child will fall prostrate or claAv the air convul- 
sively. In the severest and most dangerous type a convulsion 
supervenes. In moderately severe types of the disease the child's 
face is red or livid, the eyes bulge, and at the end of the paroxysm 
a quantity of tenacious mucoid or mucopurulent sputum is expecto- 
rated. In other cases there is vomiting at the end of the paroxysm. 
In the intervals the face is livid or pale, or the eyelids are puffy 
and the face oedematous. In some cases there are punctate hemor- 
rhages on the face, especially about the eyes and temples. There 
may be chemosis of the conjunctivae as a result of the bursting of 
bloodvessels. At this period there is in the majority of cases an 
accompanying bronchitis, with slight rise of temperature during the 
day. At first the paroxysms occurring during the twenty -four hours 
may be few ; in some cases they never become frequent, but as 
a rule they increase in number, so that the patient may have from 
twenty to one hundred in the twenty-four hours. This stage grad- 
ually declines, the number of paroxysms diminishing daily in num- 
ber and severity. They may subside suddenly or gradually after 



PERTUSSIS CONVULSIVA. 



337 



from four to twelve weeks. The whoop may at times reappear. 
After the disappearance of the whoop a cough persists for days or 
even weeks, or it may entirely disappear and suddenly recur with 
the whoop. It is characteristic of the spasmodic period of the dis- 
ease that the paroxysms should be more harassing at night than 
during the day. 

Other Symptoms. — In all cases of pertussis, even in the absence 
of complications, there is a slight increase in the number of respi- 
rations. In cases of even moderate severity the heart impulse 
is weak, and in exceptional cases the area of superficial cardiac dul- 
ness is larger than normal, indicating dilatation of a moderate 
degree. The pulse is irregular in force and rhythm, and is dis- 
tinctly more dicrotic than normal. In other words, there is a con- 
dition of heart-strain, which is evinced by dyspnoea (even in the 
absence of exertion), oedema of the face, and cyanosis. 

Kidneys. — In the majority of cases a trace of albumin is present 
in the urine ; in others, a few hyaline casts. Blood in the urine 
is seen in rare cases. 

Blood. — Leucocytosis of the polynuclear type is usually present 
in the second week of the disease. 

Complications. — One of the most common complications of 
pertussis is bronchitis. It may be mild or severe. In the severer 



Fig. 52. 


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RESP. gsSSg3SSS3 52ggSS5??5SS5 S SSSSSSSSSSSS SSSSSSSS S3 S§ 



Pertussis ; disseminated bronchopneumonia in both lungs. Infant eight months of age. 

Fatal termination. 



form the smaller bronchi are affected, with accompanying broncho- 
pneumonia (Fig. 52). The physical signs are the same as in simple 
bronchitis and pneumonia without pertussis. In some cases the 
bronchopneumonia pursues a subacute or persistent course. If reso- 



22 



338 THE SPECIFIC INFECTIOUS DISEASES 

lution takes place, other areas become consolidated. EmaciatioD is 
sometimes extreme. Emphysema is frequently present. Bursting 
of the air-vesicles may cause pneumothorax, or air may escape into 
the mediastinum and thence into the neck and into the subcutaneous 
tissue of the whole trunk. 

Hemorrhages. — During a paroxysm there may be epistaxis, con- 
junctival hemorrhage, bleeding from the ears, and petechise on the 
face and body. 

Nervous System. — Convulsions, either general or localized, may 
complicate pertussis. In the former case the outlook is grave, 
death usually taking place within twenty-four to forty-eight hours. 

Psychoses, such as melancholia and hallucinations, may compli- 
cate pertussis. Monoplegia, hemiplegia, or paraplegia, localized facial 
and oculomotor paralyses, sudden total blindness, deafness, cerebral 
hetoorrhages, hemiansesthesia, and aphasia have been observed. 

Gastro-enteritis of a fatal type may ensue. 

An attack of pertussis may favor the invasion of the tubercle 
bacillus. This may have been previously present in the bronchial 
lymph-nodes or elsewhere in the body, or it may be received into the 
body during the attack or afterward. In such cases tuberculosis of 
the lung or other organs, such as the peritoneum, develops. 

Diagnosis. — If a cough fails to improve and is especially harass- 
ing at night, later in the disease becoming paroxysmal, if the face 
becomes livid during the paroxysm, if the patient vomits after 
coughing, pertussis should be suspected and precautions taken to 
prevent its spread. As a rule, examination of the chest is nega- 
tive in the first stage. The absence of bronchitis and the presence 
of a cough of the character described, are characteristic of pertussis. 
The presence of the whoop dispels all doubt. 

Infants who have the incisor teeth and other children may, after 
the pertussis has lasted for a week, develop an ulceration of the 
frenum of the tongue, which is called a dentition ulcer. It is caused 
by friction of the frsenum linguae with ihe edges of the teeth during 
the act of coughing. These ulcerations are not diagnostic of the 
disease ; many cases do not show them, and on the other hand they 
frequently occur in coughs of other forms. 

Mortality and Prognosis. — The mortality of pertussis is greatest 
during the first year of life (25 per cent., Voit). Between the first 
and the fifth year it is about 5 per cent., and from this time to the 
tenth year, 1 per cent. (Monti). The occurrence of pneumonia in 
children under two years of age adds largely to the mortality. 
Rachitis or marasmus will militate against recovery. Hygienic sur- 
roundings render the prognosis more favorable. 

Treatment. — Prophylaxis. — The patient should be isolated, and 
should sleep in a large, well-ventilated room. During the day the 
sleeping-room may be filled for an hour with the vapor of formalin 



PERTUSSIS CONVULSIVA. 339 

(set free by means of a small formalin lamp). The object is to 
destroy suspended germs. If two communicating rooms are avail- 
able, they may be occupied alternately every twenty -four hours, the 
unoccupied room being fully ventilated in the interval. In this 
way reinfection may be avoided. 

In spring and summer, if the weather is favorable, the children 
should be constantly in the open air during the day. In large cities 
the mother is directed to take the child into the park. When in the 
open air the paroxysms are usually notably lessened. The child 
should be warmly clad in winter. Sea air seems to aggravate some 
cases and benefit others. Pine woods and moderately high altitudes 
are probably the most beneficial, for the patients are not exposed to 
the unfavorable climatic conditions peculiar to the seacoast. 

Medicinal treatment consists of inhalations, topical applications, 
and internal remedies. Simply to enumerate all the remedies which 
have been proposed and used in pertussis, would take up the 
space of a monograph. Inhalation of ozone has been advocated by 
Gail 16. The remedy is expensive and the apparatus not readily 
procurable. Inhalation of a mixture of 20 per cent, nitrous oxide 
and 80 per cent, oxygen is beneficial in cases in which the heart is 
weak. The inhalations are given with a cone for ten minutes twice 
daily. Insufflation of quinine or other drugs has not proved bene- 
ficial. The practice seemed to intensify the paroxysms. Prior, 
Coggeshall, and others have proposed the application of solutions of 
cocaine, 4 per cent, to 10 per cent., to the nares and throat. I have 
had no experience with this method, nor with the local application 
of antitussin. 

If the cough is very troublesome, I first endeavor to control it 
with full doses of antipyrin combined with tincture of digitalis. 
The digitalis, in doses of a drop or two several times daily, supports 
the heart, as is shown by the rapid disappearance of the oedema and 
cyanosis after its administration. Antipyrin is given in doses of 
grain j (0.06) for every year of age up to grains v (0.3) every three 
hours. If the cough is not perceptibly relieved by this remedy after 
forty-eight hours, I suspend its use, and give codeine in full doses 
every three hours. Codeine is to be preferred to morphine, which is 
advocated by Henoch. If vomiting is severe, the food is given in very 
small quantities in fluid form every few hours. By this method food 
is retained and absorbed, whereas a full meal is invariably rejected. 
The use of belladonna has not impressed me favorably. In several 
cases it seemed to aggravate the cough by causing a dryness of the 
laryngeal nnicous membrane. Bromoform I consider dangerous and 
of questionable utility. Quinine in full doses three or four times 
daily is a favorite remedy with many pediatrists. Vaccination and 
the injection of diphtheria serum have been proposed to abort the 
disease. I have had no experience with the serum treatment. In a 



340 THE SPECIFIC INFECTIOUS DISEASES 

word, the treatment of pertussis consists in applying the rules of 
hygiene, in mitigating the cough with antipyrin or preferably 
codeine, and in supporting the heart with digitalis. The compli- 
cations should be treated on the principles laid down in the sections 
on Bronchitis, Pneumonia, and Pleurisy. 

XV. DIPHTHERIA. 

Diphtheria is a contagious febrile disease which aifects the throat 
and air-passages. It is characterized by the formation of a pseudo- 
membrane on the parts affected. The disease manifests itself by a 
local lesion and general symptoms caused by the entrance of toxins 
and, at times, of bacteria into the blood and lymph. 

Age and Occurrence. — Although diphtheria is uncommon in 
the newly born infant, statistics of large numbers of cases show a 
certain percentage in these subjects ; thus, of 547 cases reported by 
Monti, the newly born number 24, and in Baginsky's statistics 
several cases are noted. The disease is more frequent from the first 
to the third month than from the third to the tenth month (Monti). 
The largest number of cases occur from the second to the sixth 
year (40 to 63 per cent.) (Monti, Baginsky). 

According to Seitz, it is slightly more frequent among boys than 
girls. Strong as well as weakly children are attacked. Children 
who suffer from nervous affections, such as poliomyelitis, are more 
likely to contract the disease than others (Baginsky). All exposed 
to infection do not contract the disease, because some individuals are 
immune. Escherich and Fischl have proved that the blood of con- 
valescents contains antitoxic elements. Cases of several attacks in 
the same individual are not uncommon. Racial peculiarities have 
no influence. 

Diphtheria is prevalent in all parts of the world and epidemics 
occur at all seasons of the year. It is more common among the 
poorer classes, not on account of uncleanliness, but as a result of 
overcrowding. 

Contagion. — Diphtheria is contagious from person to person, 
and may be conveyed by any one who has been in the room occu- 
pied by a patient with the disease. Mild cases may give rise to fatal 
cases. The disease is infectious, spreading through families and 
schools, and may be conveyed through the medium of toys, clothes, 
and in milk. 

Period of Incubation. — This has not been determined with any 
accuracy in diphtheria. Two to eight days, or an average incubation 
of three days, is laid down by most observers, but no accurate data 
are available on this important point. Some authors place twenty 
days as an extreme limit of incubation. This latter period is evidently 
only founded on surmise. 

Etiology. — The essential cause of diphtheria is a bacillus, the 



DIPHTHERIA. 



341 



Bacillus dlphtVierise, which was first noted in stained specimens 
by Klebs in 1882. Loffler first isolated and accurately described 
it in 1884. It is present in all cases of true diphtheria of 
Bretonneau. In the 3 per cent, of cases in which it is reported 
absent there is good reason to believe that failure to establish its 
presence was due to imperfect technique. The bacillus is non-motile, 
twice as thick and about as long as the tubercle bacillus, thickened 
at the extremities, has no spores, and in some forms has been de- 
scribed as branching. It is very resistant, adheres to clothes and 
candy, and has been found in milk. It will retain vitality a long 
time in dried membrane (seventeen weeks), as has been shown by 
Roux and Yersin. It has been detected nine weeks after the disap- 
pearance of the membrane from the throat. It is found present with 
other bacteria, principally staphylococci and streptococci, pneumo- 
cocci. Bacillus coli commune, pyocyaneus, proteus, and sprue. It has 
been found by Roux and Yersin in the throats of perfectly healthy 



Fig. 53. 



Fig. 54. 



S I 



V 
















J 









<*■ « *i* 









The Bacillus diphtherise (Klebs-Loffler). 
Fig. 53.— Pure culture, photomicrograph. Fig. 54.— Pure culture, photomicrograph. 

X 1000. X 1000. Shows the irregular beaded stain. 

individuals, and may be present without the formation of a mem- 
brane. It has been shown that this bacillus forms toxins of very 
positive action. According to Sidney, the toxins of diphtheria may 
be divided into albuminoses and organic acids. 

The pseudobacillus of diphtheria was first isolated by Hoffman. 
In its growth and staining properties it is identical with the true 
diphtheria bacillus, but is not virulent to animals. Roux and Yersin 



342 



THE SPECIFIC INFECTIOUS DISEASES. 



regard it as a weakened diphtheria bacillus. Others believe that it 
bears no relation to the true bacillus. It is found associated with the 
true bacillus, and also in cases of diphtheria after this bacillus has 
disappeared from the throat (Koplik). Some authors have given 
the name pseudodiphtheria bacillus to another variety of bacilli, but 
this term should be strictly limited to the form described above. 

General Infection with the Bacillus Diphtheriae alone and with Other 
Bacteria. The bacillus of diphtheria was first demonstrated by Frosch 
(1895) in the heart's blood, liver, spleen, kidneys, and lymph-nodes. 
Since then, Kolisko, Paltauf, Schmorl, Booker, Councilman, Mallory, 
and Wright have demonstrated its presence in the blood and internal 




1 and 3. Cultures of the pseudobacillus of diphtheria on agar, stiowinjr the diffuse char- 
acter of the growth. 2. Growth of Bacillus diphtherias (Klebs-Loffler) on the same medium. 
It is a delicate growth in colonies. 

organs in fatal cases of diphtheria. The work of Councilman and 
his pupils is the most recent and complete on this subject. They 
show that the bacillus may occur alone or in association with strep- 
tococci or staphylococci in the blood, lungs, liver, spleen, and kidney. 
It is more likely to be found alone in fatal cases of uncomplicated 
diphtheria. The mixed infections with streptococci and other bac- 
teria occur in diseases, such as scarlet fever and measles, which may 



DIPHTHERIA. 343 

be complicated with diphtheria. The investigators just mentioned 
found endocarditis, bronchopneumonia, empyema, mastoid disease, 
and thrombosis of the sinuses due to the diphtheria bacillus. The 
bacillus was found also in the pus of acute abscesses in various 
localities. 

Morbid Anatomy. — In fatal cases the membrane appears as a 
thick brownish or grayish-brown mass. It is sometimes present as a 
thin whitish pellicle, and occasionally is almost black. It may be 
friable or as resistant as cartilage, and may extend over the tonsils, 
palate, pharynx, base of tongue, epiglottis, and trachea. The areas 
not covered by membrane are injected, and may be the seat of hemor- 
rhages. The tonsils are enlarged and bluish red. In the gan- 
grenous forms the tonsils, soft palate, and uvula may be converted 
into necrotic masses. The nasal passages may show membranous 
deposit. The epiglottis and vocal cords are thickened. The tracheal 
mucous membrane is hypersemic and swollen, there may be adherent 
membrane, or the pseud omembrane may be loose and curled up in 
the lumen of the trachea. 

The membrane itself has been described by Yirchow as croupous 
and diphtheritic. Councilman is of the opinion that little is to be 
gained by adhering to the old classification of croupous and diph- 
theritic membranes. Baginsky also describes forms of diphtheria in 
which the membrane possessed both croupous and diphtheritic struct- 
ural characteristics. According to Councilman, the first step in the 
formation of the membrane is a degeneration and necrosis of epithe- 
lium, preceded by a proliferation of the nuclei of the cells. Detritus 
and hyaline masses result. An inflammatory exudate rich in fibrin is 
thrown out from the underlying tissue. The fibrin forms in part a 
reticulum enclosing cells and degenerated epithelium, and in part a 
hyaline reticulated membrane. The hyaline membrane is formed on 
surfaces which are covered with several layers of epithelial cells. 
Fibrinous membrane is formed on the surface and in the tissue. By 
constant accretions thick masses are formed. The membrane is never 
formed on an intact epithelium, but may extend over it. There is 
nothing specific in the diphtheritic membrane. The connective tissue 
and the bloodvessels beneath the membrane may be the seat of hya- 
line degeneration. The mucous glands are degenerated. 

The diphtheria bacilli are found growing in the necrotic tissue 
and in the exudation, never in the living- tissue or in epithelium 
undergoing primary degenerative changes. In exceptional cases 
they may be found enclosed in pus-cells and necrotic epithelium. 
They are found in masses, and when deeply situated have been 
covered up by later formation of membrane. 

Heart. — Councilman, Mallory, and Pearce have recently described 
the myocarditis sometimes complicating diphtheria. There is a fatty 
change in foci or in more diffuse areas in the muscle-fibre. In 
another form of myocarditis there are interstitial changes, consisting 



344 THE SFECIFIC INFECTIOUS DISEASES. 

of focal collections of plasma and lymphoid cells, and the forma- 
tion of new connective tissue, resulting in some cases in a fibrous 
myocarditis. These pathologic changes are due to the action of the 
diphtheria toxins on the heart-muscle. 

The Lungs. — Councilman states that the most common lesion in 
fatal cases is a bronchopneumonia, lobar pneumonia never being 
present. The process begins in an infection of the atria. The bac- 
teria found in the lung, and which are present independently of the 
character of the lesion, are the pneumococcus (rarely). Streptococcus 
pyogenes, and the diphtheria bacillus. Marrow-cells are found in the 
capillaries, and thrombi in the larger vessels. The lymphatics are 
dilated and contain fibrin and cells. 

The spleen macroscopically is normal ; microscopically, the 
lymph-nodules are more prominent than is normal, and contain foci 
of epithelioid cells. The vessels are the seat of hyaline degenera- 
tion, and in the later stages contain large numbers of plasma-cells. 
Some of the nodes may be the seat of necrosis and abscess. 

Liver. — The changes in this viscus are due to the action of toxins, 
and consist of parenchymatous degeneration and necroses, seen 
especially in the centre of the lobules. There is slight hyaline de- 
generation of the capillaries. 

Kidneys. — There may be simple degeneration or acute nephritis. 
The severe forms of nephritis are found in the cases which are 
quickly fatal (Councilman). The interstitial and glomerular changes 
are more common in older children and in protracted cases. There 
is no specific form of nephritis in diphtheria, and all the changes are 
due to the action of toxins. 

Lymph-nodes. — The mesenteric lymph-nodes, the nodes at the angle 
of the jaw and in the retropharynx and oesophagus are enlarged, and 
may undergo necrotic changes (Flexner). Councilman, Mallory, 
and Pearce describe the changes in the lymph-nodes as being more 
marked in those nearest the lesion. There are congestion, hemor- 
rhages, and diffuse and circumscribed necrosis. In addition there is 
a formation of foci resembling miliary tubercles, and composed of 
epithelioid cells which undergo degeneration, forming granular de- 
tritus. Bacteria are not found in the nodes. The changes are due 
to the toxins. 

Nerves. — There are fibrillation, increase of the cells of the sheath 
of Schwann, fatty degeneration of the axis-cylinder, hemorrhages, 
and nodular degeneration of the nerve-sheaths. In the spine there 
are infiltration of the meninges, hemorrhages, and degeneration of 
the anterior horns. Degenerative oculomotor changes are present. 
There are dilatation and round-cell infiltration around the central 
canal of the cord. 

Stomach. — Diphtheritic membrane in the stomach occurring in 
cases of diphtheria has been described by Smirnow and Council- 
man. Of 220 cases reported by the latter, 5 showed the pres- 



PLATE XII. 






GrDapa 



(Day 



1. Tonsillar Diphtheria, with a small patch of membrane 

on the uvula. 

2. Tonsillar Diphtheria, with a patch of membrane on the 

pillars of the fauces. 
8. Acute Follicular Amygdalitis, which may be diphtheritic. 



DIPHTHERIA. 345 

ence of membrane to a greater or less extent. The membrane 
either covered the whole surface or formed patches or streaks over 
the rugse. The mucous membrane was swollen, hypersemic, or 
hemorrhagic. 

The Middle Ear. — Of 144 cases reported by Councilman, Mal- 
lory, and Pearce, 86 showed involvement of the middle ear on one 
or both sides ; in 7 the mastoid was aifected. The inflammatory 
products were serum or pus. The organism most constantly present 
was the streptococcus, but the diphtheria bacillus has been found, as 
have also the staphylococcus and pneumococcus. 

The Blood. — The specific gravity is increased at the height of the 
disease. In mild cases it is not perceptibly changed ; in severe 
septic cases it may range from 1054 to 1060 (Baginsky). Haemo- 
globin is reduced only in severe cases of protracted course. Leuco- 
cytosis is not marked in mild cases, but in severe septic forms an 
increase of the white blood-cells has been observed by Felsenthal 
and Monti. In malignant cases there is a reduction in the number 
of red blood-cells (Ewing, Billings, Morse). 

Symptoms. — Clinically, it is convenient to divide diphtheria 
into the purely local forms with few constitutional symptoms, the 
local forms with symptoms of marked toxaemia or septic forms, and 
the laryngeal forms. 

Purely Local Forms with Slight Constitutional Disturbances. — In 
diphtheria sine membrana, synanche contagiosa (Senator), or catar- 
rhal diphtheria, there may be no formation of membrane, the fauces 
showing only an angina of varying severity. In some cases there is 
the picture of a follicular or lacunar amygdalitis. Macroscopically 
there is nothing to show that the process is diphtheritic (Plate 
XII). In other forms the membrane is present on the tonsils as 
specks or strips of exudate, or white or greenish pultaceous masses 
which may extend to the uvula, or there may be spots or extensive 
plaques on the posterior pharyngeal wall. In other mild cases the 
process is confined to a small necrotic excavated area in one or the 
other tonsil, as described by Henoch. In still other forms the 
membrane may cover both tonsils, and extend over the soft palate 
and pillars of the fauces. In these forms of localized diphtheria 
the nares are seldom involved. 

In these localized forms of diphtheria the infant or child may 
present few symptoms pointing to the throat affection. Unless the 
physician be systematic in his methods of examination, he may fail 
to inspect the throat at his first visit, and the diphtheria may thus 
escape detection. The nursling in this as in the non-diphtheritic 
affection, may refuse to take the breast. The movements are green- 
ish, and have an offensive odor, or may be diarrhoeal. There are 
fever and restlessness. Inspection will reveal slight or marked 
swelling of the lymph-nodes at the angle of the jaw. The temper- 



346 THE SPECIFIC INFECTIOUS DISEASES. 

ature may not be above 101° F. (38.3° C.) or may be as high as 
105° F. (40.5° C). As a rule, it is not persistently high. The 
pulse is accelerated and the respirations slightly increased. The 
invasion of the disease is for the most part insidious in nurslings ; 
rarely is there a chill or convulsion. The tonsils are enlarged, and 
show small specks or plaques of membrane on their surface. The 
uvida may be red and swollen, and there may be patches of mem- 
brane on the sides adjacent to the tonsils. There is sometimes a 
croupy cough. In purely local diphtheria, however, the larynx is 
not involved in the majority of cases. The urine may show a trace 
of albumin, and in some cases a few leucocytes, blood-cells, and a 
very fcAV hyaline casts. In older children the signs of illness are 
more marked. They complain of pain on swallowing, and the 
temperature may at first be high. Toxsemic symptoms, such as pain 
in the joints, headache, pain in the back, and slight prostration, are 
present. Inspection of the throat may show the tonsils to be enlarged, 
and to present the appearances mentioned above. Other members of 
the family may complain of sore throat. I have reported cases in 
which children complained of but few symptoms and engaged in their 
customary play. Examination of their throats disclosed the presence 
of simple inflammatory redness and swelling of the tonsil, pharynx, 
and uvula. In these cases the diphtheria bacillus was detected in 
scrapings from the fauces. Membrane never developed, and yet 
they were cases of true diphtheria. 

The fever is not characteristic. The temperature may at first 
reach 104° F. (40° C.) or above, and gradually drops to the normal 
with subsidence of the symptoms. Otitis and suppuration of the 
submaxillary and retropharyngeal lymph-nodes may cause the tem- 
perature to become remittent or intermittent. 

Septic Form of Diphtheria. — In the second clinical form of diph- 
theria there are, in addition to the local symptoms present in the 
first form, constitutional symptoms of a severe or even septic type. 
The children at the outset appear very ill ; the temperature is high, 
there is marked restlessness with a tendency to drowsiness, the face 
is flushed, and the breathing noisy or nasal. The infants refuse the 
breast or bottle, and older children complain of great pain in swal- 
lowing. In some cases the glands at the angle of the jaw are 
swollen, and the neck is more rotund than normal. Inspection of 
the throat shows the membrane on the tonsils, or on both uvula and 
tonsils. It spreads rapidly, the tonsils, soft palate, and pharynx 
being covered in one or two days. The membrane may break down, 
and masses of necrotic tissue be expectorated. In severer forms the 
membrane extends over the posterior nares, and gradually invades 
the nasal passages. At first a slight nasal serous discharge is 
noticed, which increases in amount and becomes ichorous and tinged 
with blood ; the anterior nares become eroded and are coated with a 



DIPHTHERIA. 347 

whitish or greenish membrane. In some cases the membrane in- 
volves the buccal mncons membrane. There is severe stomatitis, 
the lips are eroded, and the angles of the mouth may show rhagades 
covered with membrane. With the development of these symptoms 
the toxaemia increases ; the fever may be moderate, not exceeding 
102° or 103° F. (38.8° or 39.4° C.) ; the pulse is rapid and feeble ; 
the sensorium somewhat benumbed. The lymph-nodes at the angle 
of the jaw may be much enlarged, and the tissue underneath the jaw 
may be the seat of phlegmonous inflammation. The breath has a 
very fetid odor. The urine may reveal the presence of albumin, a 
slight amount of blood, and a few casts of the hyaline or epithelial 

The constitutional symptoms may diminish in severity, and with 
the subsidence of the local symptoms the appetite returns, the 
sensorium brightens, and recovery gradually takes place. On the 
other hand, if a fatal issue occurs, it results from heart paralysis, 
paralysis of the general nerv^ous system and respiratory function, or 
extension of the diphtheritic process to the larynx, trachea, and 
lungs. 

If the diphtheria extends to the larynx, the voice becomes first 
husky, then croupy. The breathing is labored and of the laryngeal 
or croupy type, there is retraction of the suprasternal notch and 
epigastrium, the accessory muscles of respiration are drawn into play, 
and unless relieved the patient dies of suifocation. Even if relieved, 
when the septic symptoms and toxaemia are severe the patient may 
succumb or the process may spread downward, and involve the 
trachea and lungs. In those cases in which there is cardiac paraly- 
sis, vomiting and abdominal pain supervene. The patient is pale 
and the surface cool. Gallop rhythm sets in and the heart-sounds 
become indistinct. The expression is at first anxious, then apa- 
thetic ; the voice is scarcely audible ; the patients no longer notice 
their surroundings. Death ensues from pulmonary oedema with 
symptoms of heart-failure. 

If the general nervous system is involved, paralysis of the soft 
palate sets in even after the membrane has disappeared from the 
€onsils and pharynx. The reflexes are absent, and the child is 
unable to sit upright. The act of swallowing not only becomes diffi- 
cult, but fluids may find their way into the larynx and thence into 
the trachea, causing pneimionia ; or the paralysis may extend to the 
diaphragm, when the lethal issue is hastened by paralysis of the 
respiratory apparatus. 

The Malignant Septic Form. — -This form has been partly described 
above. It is characterized not only by the malignancy of the local 
process, but by the severity of the toxsemic symptoms as well. It 
was formerly believed that these cases were due to mixed infections 
with streptococci and staphylococci, but it is now known that the 



34S TSE SPECIFIC INFECTIOUS DISEASES. 

Bacillus diphtheria^ alone may cause all the symptoms. In these 
cases not only the toxins, but the bacillus itself also enters the cir- 
culation. The pharynx, tonsils, and nares are covered with a dirty 
brown or greenish membranous exudate. There is an ichorous dis- 
charge from the nares. The tonsils, pharynx, and lymph-nodes of 
the neck become necrotic. The membrane is discharged from the 
nose and mouth. The fetor of the breath is extreme, and the pros- 
tration correspondingly great. The larynx, trachea, and lungs may 
be involved in the diphtheritic process. The pulse is weak and 
rapid. The temperature may not be above the normal, and in some 
cases may be subnormal. Acute nephritis may be present. In some 
cases hemorrhage under the skin and from the nose, mouth, bowel, 
and even kidney, may precede death. 

A few cases recover, but in them the necrosis of tissue in the 
pharynx and larynx causes permanent defects and cicatricial con- 
tractures. Loss of the uvula and perforations of the soft palate may 
result from diphtheria in early life. 

Laryngeal diphtheria (croup) is the result of the extension of a 
mild or severe tonsillar or pharyngeal diphtheria. There may be no 
preceding clinical manifestations. There are the rare cases of so- 
called ascending croup, whose existence has not been wholly dis- 
proved. Cases are seen in which the most careful inspection has 
failed to detect preceding disease of the pharynx, epiglottis, or tonsils. 
Lastly, there is a class of cases which occurs during convalescence 
from pharyngeal or tonsillar diphtheria. 

The symptoms vary accordingly as the disease manifests itself 
first in the larynx or follows a localized tonsillar or pharyngeal diph- 
theria. In the latter case there may be slight redness of the tonsils 
or pharyngeal mucous membrane, or the parts above the larynx 
may show membranous deposits. In either case the laryngeal 
invasion is ushered in by croupy cough and stridulous or metallic 
breathing. The cough is harassing and persistent, and the stridor 
increases within twenty-four or forty-eight hours to such an extent 
as to be distinctly audible, and to give the impression that there 
is a mechanical obstruction in the larynx. The breathing becomes 
labored, and there is retraction of the parts above the sternum 
and of the peripneumonic groove, especially at the epigastrium. 
In rachitic infants the sides of the chest and the epigastrium are 
markedly retracted at each descent of the diaphragm. With increas- 
ing obstruction the face assumes an anxious expression, the lips 
become cyanosed, and the surface cool. The pulse is rapid — 120 
to 180. The fever may be high or low. The lividity of the face 
in the severer forms of dyspnoea gives place to pallor. The picture 
of laryngeal obstruction, with the stridulous breathing, increased 
respirations, and overaction of the accessory muscles of respiration, 
is so characteristic as to be significant to even the inexperienced 



DIPHTHERIA. 349 

observer. During the paroxysms of coughing membranous casts are 
expelled from the larynx. The membrane may extend downward, 
involving the trachea and bronchi, casts of which may be expelled. 
The lungs may become involved, and in severe cases are the seat of 
a bronchopneumonia of streptococcic nature. With this there may 
be compensatory emphysema. The urine may show the existence of 
slight or extensive nephritis, or may be normal in every respect. 

Especially deceptive are those cases of membranous laryngeal 
diphtheria or croup whose onset closely resembles that of so-called 
catarrhal laryngitis. In these the symptoms may develop suddenly, 
and within twenty-four hours the patient presents all the symptoms 
of laryngeal obstruction (croup d'emblee of the French). Inspection 
may show little variation from the normal appearances in the pharynx. 
We should be cautious not to assume that no membrane is present in 
the larynx. Cases have been recorded in which laryngoscopic exam- 
ination failed to show membrane in the larynx, but in which post 
mortem it was found present beneath the cords and in the trachea. 

Course and Duration. — In the mildest and purely local forms 
the disease reaches its height in from two to four days ; the tem- 
perature then drops to the normal and convalescence is established. 
In the severe septic forms the membrane spreads from the tonsils 
to the pharynx, and the disease attains its full development in from 
five to eight days. The temperature falls by lysis or crisis, and 
convalescence is established. If the case is very severe, the disease 
shows no tendency to limit itself, the toxaemia is extreme and the 
involvement of the lymph-nodes is very great. Death may ensue 
in from a week to fourteen days. In some very malignant cases 
death may ensue in from three to four days after the onset of the 
disease. The laryngeal diphtheritic croup reaches its full develop- 
ment as a rule early — within three days. The disease may then 
retrograde under treatment or may advance into the trachea and 
bronchi, and cause death in a variable length of time. 

The complications include bronchopneumonia, pleuritis, gastro- 
enteritis, retropharyngeal abscess, suppuration or necrotic destruc- 
tion of the lymph-nodes of the neck, nephritis, cardiac paralysis, 
early and late (or post-diphtheritic) general paralysis, and diphtheria 
of the eyes, skin, and vulva. 

Bronchopneumonia and Pleuritis. — Bronchopneumonia is found 
in from 50 per cent. (Baginsky) to 80 per cent. (Talamon) of the 
autopsies on children who have died of diphtheria. It results 
from extension of the disease from the trachea into the smaller 
bronchi and alveoli of the lung, and is therefore always a true 
bronchopneumonia. Through the investigations of Loffler, Flex- 
ner, Northrup, and Prudden, it has been proved that the diphtheria 
bacillus, the Streptococcus pyogenes, the Staphylococcus pyogenes, 
and the pneumococcus are the exciting causes of the pneumonia. In 



350 THE SPECIFIC INFECTIOUS DISEASES. 

the pneumonia resulting from the diphtheritic or pseudodiphtheritic 
processes complicating scarlet fever and measles, Prudden and 
Northrup have shown that the Streptococcus pyogenes is an active 
causal agent. The onset of a complicating pneumonia is generally 
indicated by an exacerbation of the dyspnoea, fever, and cough. 
The prostration is also more marked. Auscultation of the inferior 
lateral or posterior parts of the chest on one or both sides reveals 
the presence of bronchopneumonia ; while resolution is taking place 
in one part of the lung, other areas are being involved. Thus an 
apparent improvement may be followed by a rapid rise of tempera- 
ture, increased dyspnoea, and rapid pulse. This form of broncho- 
pneumonia may be complicated by pleuritis of a serous, serofibrinous, 
purulent, or hemorrhagic type. 

Gastro-enteritis. — In nurslings there is frequently a diarrhoea with 
green stools and vomiting. In some cases these symptoms may 
become severe. Extension of the membrane into the oesophagus, 
stomach, and gut may take place, with a fatal result. The cases of 
simple diarrhoea are directly due to the swallowing of bacteria from 
the mouth and fauces. The diarrhoea may be so severe as to become 
one of the leading features of the disease. 

Retropharyngeal abscess occurs in the tonsillar and pharyngeal 
forms of diphtheria as a result of infection of the retropharyngeal 
lymph-nodes by streptococci. 

Nephritis may be absent, slight, or severe. Baginsky found it 
present in 42 per cent, of his cases. In the majority of cases of even 
mild diphtheria there is albuminuria ; in some the urine may, in 
addition, contain casts, blood-cells, renal epithelium, and leucocytes, 
showing grave lesions of the kidneys. 

The affection of the kidneys is brought about by the action of 
the toxins on the parenchyma of the kidney. Not only are toxins 
produced in the kidney substance, but bacilli have been found in the 
kidney and in the urine. A large percentage of the cases of nephri- 
tis are of the mild type. Here, as in scarlet fever, we have cases in 
which there is nephritis with blood-casts and ursemic symptoms in 
the course of the disease, and cases in which there is total suppres- 
sion. All are agreed that oedema and anasarca of the body are un- 
common, even in the presence of severe nephritis. I have seen 
severe septic forms of pharyngeal diphtheria ushered in with vom- 
iting and uremic symptoms, such as headache and exhaustion, before 
the appearance of the membrane. These symptoms subsided when 
the membrane was fully formed, to be followed in a few days by 
complete suppression of urine after the disappearance of the mem- 
brane. In one of my cases the membrane had entirely disappeared 
from the throat and the patient was apparently convalescing when 
total suppression set in, continued for several days, followed by 
ursemic convulsions and death. 

Heart Paralysis. — Of greatest clinical significance is the cardiac 



DIPHTHERIA. 351 

diphtheritic paralysis, which may become apparent either early 
during the course of the disease or later on in convalescence. The 
earjy form may set in while the membrane is still visible in the 
throat. It occurs in the septic forms of the disease. These are 
the severe cases. The children show great prostration and apathy ; 
the pulse is rapid and irregular ; the heart-sounds, especially the 
muscular sound, is indistinct ; the pulse is feeble and flickering ; 
there are vomiting and abdominal pain. These symptoms may 
repeat themselves in attacks, until finally the patient dies with all 
the symptoms of collapse, such as cool extremities and shallow 
respirations. In such cases there is, as a rule, a marked nephritis. 
In the late cases the symptoms of cardiac failure appear from the 
second week of the disease to the seventh week of the convalescence. 
The membrane has disappeared from the throat. There may be 
no premonitory symptoms, or there may have been a slight blowing 
murmur at the apex. In their mildest form the heart symptoms 
appear in the second or third week. The heart becomes irregular, 
and the muscular sound is weak ; the pulse becomes small and 
either slow or rapid (tachycardia). There may be attacks of syncope, 
during which the patients vomit, complain of abdominal pain, and 
refuse medicine and nourishment. Sudden cardiac failure and death 
without symptoms, premonitory or otherwise, may occur in the 
period of convalescence. 

Mild forms of cardiac irregularity which do not eventually prove 
fatal are seen in the beginning of convalescence. There are forms 
of cardiac irregularity which may appear alarming at first and in 
which complete recovery results. Thus, as will be seen under the 
heading of Myocarditis, it is not uncommon in the convalescence, 
early or late, to observe the heart become irregular. This irregu- 
larity increases from day to day. In its most pronounced form I 
have observed it in a child three years of age, in whom the heart 
would contract two or three times, there would then be a pause, fol- 
lowed by two or three or four contractions. The pulse varied from 
80 to 96 during sleep, and 110 to 130 in the waking state. The 
compressibility of the pulse varies in these cases ; the heart-beat is 
weak, or at times may be strong. The second sound will be at the 
pulmonary orifice. In these cases the child is apparently comforta- 
ble. There is no pericardial distress, pain, or vomiting ; there may 
be occasional sighing. The cardiac irregularity may persist for 
days, even weeks, and ultimate recovery result. It is not always 
in the severe cases of diphtheria that these symptoms of cardiac dis- 
turbance appear, but in the apparently mild cases of short duration. 
The severe forms of cardiac paralysis set in with symptoms of the 
early cases. These symptoms may have been preceded by the milder 
symptoms of cardiac irregularity. There is slight albuminuria. Sud- 
denly, while in apparent good health, the patients complain of 
dyspnoea and pain in the stomach. The lips become cyanosed and 



352 THE SPECIFIC INFECTIOUS DISEASES. 

the extremities cool, the pulse thready, the heart impulse weak, the 
heart-sounds scarcely audible ; the heart may be rapid or as slow as 
40 to 50 beats per minute. Vomiting is repeated, and in some cases 
the liver is enlarged, as also the spleen. I find in all cases of diph- 
theritic myocarditis that the enlargement of the liver and spleen 
with the increase of the pulse rate is a symptom of very serious 
moment, and, as a rule, a precursor of a fatal issue. The patients 
may survive one or two such attacks, only to succumb finally. In 
the early forms of cardiac paralysis there may be no gross lesions in 
the heart-muscle. In the later forms the lesions are more apparent. 
There are fatty parenchymatous changes. In other cases there may 
in addition be changes in the vagi. 

Diphtheritic Paralyses. — Paralyses are the result of the action of 
the toxins of the Bacillus diphtherise on the nerve-trunks and tissues 
of the general nervous system. The paralysis may occur in the 
course of the disease or during convalescence. When the paralysis 
occurs early, it aifects the velum pendulum palati. In cases which 
result fatally the heart becomes aifected, pneumonia caused by the 
passage of food into the larynx develops, or the paralysis may 
become general. In the latter case the symptoms are similar to 
those seen in the post-diphtheritic forms of paralysis. This form 
of paralysis manifests itself from the second to the sixth week after 
the onset of the disease. In mild forms, it may begin with a paralysis 
of the muscles of the soft palate, which remains localized. The child 
has a nasal tone of voice, and liquid food is regurgitated through the 
nose on swallowing. In severe cases there are in addition loss of 
the patellar reflexes, ataxic conditions, inability to sit upright or to 
stand, oculomotor paralysis, facial paralysis, pallor, weak heart, 
arhythmia, loss of appetite, and albuminuria. 

Recovery may take place even when there is general involvement 
of the muscles. The great danger is extension of the paralysis to the 
diaphragm. Post-diphtheritic paralysis occurs in 5 to 7 per cent, 
of the cases of diphtheria, according to Baginsky, who reported 131 
cases of paralysis in 2300 cases of diphtheria. The soft palate was 
most often aifected. Among the other forms of paralysis are 
those of the facial and oculomotor nerves, the larynx (recurrent 
laryngeal), and lastly forms of ataxia. Antitoxin has little effect in 
preventing these paralyses. They occur as frequently after its ad- 
ministration as during the pre-antitoxin period. 

In the American Pediatric Society's tabulation 9.7 per cent, of the 
cases had paralysis ; of these, 32 out of a total of 328 cases died of 
cardiac paralysis. 

Hemiplegic cerebral palsy may occur in diphtheria (Monti, Levi, 
Baginsky). 

Disturbances of the sensory nerves also occur in diphtheria, such 
as perversions of the senses of smell and taste ; also anaesthesia of 
the rectum. 



DIPHTHERIA. 353 

Psychical derangements such as melancholia have been reported. 

Diphtheritic Ophthalmia. — True diphtheritic ophthalmia occurs 
both as an accompaniment of diphtheria of the fauces and as an 
idiopathic affection. There are two distinct forms of pseudomem- 
branous affection of the eye. In the first, the Lofiler bacillus is 
present, but in the second, or diphtheroid form, it is absent, and 
the streptococcus alone is found. Of the true diphtheritic form, 
one class of cases has a mild clinical course. In these the bacillus 
isolated resembles the pseudodiphtheria bacillus in not possessing 
virulent properties. In the other form of diphtheritic eye affection 
the membrane spreads rapidly and causes destruction of the eye. 
The diphtheritic invasion is ushered in with redness and chemosis. 
The membrane appears first on the palpebral conjunctiva, and causes 
marked swelling of the lids. There is little seropurulent discharge. 
In the progressive form destruction and perforation of the cornea 
result. I have seen several cases in connection with fatal diphtheria 
complicating measles, and also cases in which there was no history 
of diphtheria in the patient or family. I have seen it occur as an 
idiopathic affection in nurslings. According to Baginsky, diphtheritic 
ophthalmia occurs in 3 per cent, of the cases of diphtheria, and is 
most frequent from the second to the sixth year. 

Diphtheria of the skin occurs w^hen the specific bacillus finds 
lodgement in an abrasion or cut. The membrane spreads over the 
wound and encroaches on the surrounding skin. 

Diphtheria of the vulva is met with both as an idiopathic affection 
and as a complication of true diphtheria elsewhere in the body. 
I have not found the Klebs-Loflfler bacillus in a number of pseudo- 
membranous inflammations of the vulva and vagina in infants. Some 
of these cases show the presence of true membrane ; others begin as 
aphthous ulceration and develop membrane later. These cases are 
benign. The diphtheritic bacillary cases may be divided into two 
distinct classes according to their causation. The cases of one class 
show the Loffler bacillus, but are benign in course, although I have 
proved by animal experiment the presence of the bacillus of diph- 
theria in virulent form. In the other class of cases there is extensive 
destruction of tissue, and sometimes a fatal result. Cases of this 
class occur as a complication of diphtheria elsewhere in the body or 
in connection with the exanthemata. 

The symptoms of diphtheria of the vulva and vagina may be 
localized strictly to the parts, or there may, as in the severer forms 
of Henoch, be constitutional symptoms of toxaemia. Locally, the 
disease is characterized by the appearance of patches of membrane 
on the inner surface of the labia, clitoris, and introitus vaginse. The 
parts, especially the labia majora, are intensely swollen and oedem- 
atous. In Henoch's cases there was gangrene or necrosis of neigh- 
boring tissues. In my cases there was no complicating diphtheria 
g3 



354 THE SPECIFIC INFECTIOUS DISEASES. 

of other parts. The cases occurred in infants and in children under 
two years. They were benign in course, although of bacillary type. 

Nasal Passages. — Councilman, Mallory, and Pearce, in their latest 
monographs on diphtheria, call attention to the frequency of invasion 
of the accessory sinuses of the nose and antrum by the diphtheritic 
process. They found the antrum affected in 33 cases of 52 ex- 
amined. Clinically, this affection is more common than appears 
from these figures. This would account, according to these authors, 
for the persistence with which diphtheria bacilli continue in the nasal 
secretions after the throat lesions have disappeared. The disease of 
the antrum may, as pointed out by Wolff, and recently by Mayer, 
persist after the diphtheria has run its course. Mayer classifies the 
symptoms as eversion of the lower lid, fistulous opening in the cheek 
from which pus exudes, and a fetid purulent discharge from the nose 
on the side of the face at which the fistula is situated. 

Other Complications. — Diphtheria in pertussis is a serious compli- 
cation, since the resistance of the patient is generally much decreased. 
Bronchopneumonia is especially to be feared. In tuberculosis the 
patient usually dies as a direct result of the complication. In measles 
the diphtheritic process is a grave complication ; it may invade the 
larynx and death may ensue from extension of the disease to the lungs. 
In typhoid fever the process causes death by invasion of the lungs. 

Exanthem. — Is there an exanthem characteristic of diphtheria ? 
I am inclined to view all eruptions which may occur in the course of 
this disease as purely accidental. They may be the result of reme- 
dies (antitoxin) administered or of some infection originating in the 
gut. Among these eruptions are the various forms of erythema and 
roseola. Erythema urticatum is often seen. 

The diagnosis of diphtheria must be considered in its clinical 
and bacteriological aspects. Clinically the characteristic and ever- 
present lesion is the membrane. This is seen on the tonsils, uvula, 
pillars of the fauces, and the posterior pharyngeal wall. Its color 
varies. In consistency it may vary from a thin pellicle or cloudy 
discoloration to a thick adherent, pultaceous or stringy mass. In a 
large proportion of cases the presence of the membrane and other 
characteristics are presumptive evidence of diphtheria. On the 
other hand, there are certain forms (not very frequent) of pseudo- 
membranous inflammation of the tonsils and fauces which are not 
truly diphtheritic ; these are called pseudodiphtheria or diphtheroid. 
In these cases the Klebs-LofEer bacillus is not found, but strepto- 
cocci, staphylococci, and other bacteria are present. Some forms 
of diphtheria show at first only fibrinous specks on the tonsils ; in 
others there are small necrotic ulcerations on the tonsil, and in still 
others the diphtheria may simulate an acute catarrhal follicular 
amygdalitis or lacunar amygdalitis. These cases are not as infrequent 
as was formerly supposed. In the pseudomembranous and other 



DIPHTHERIA. 355 

forms of inflammation of the throat above described a bacteriologi- 
cal test should always be made. It should be practised as a routine 
procedure in all cases of angina. Cultures should be made in cases 
of laryngeal inflammation in which no membrane is visible in the 
fauces. If membrane be present in the fauces, and a culture fail to 
reveal the Klebs-Lofiler bacillus, a second and even a third culture 
should be made. I have frequently established the presence of the 
specific bacillus in membrane in cases in which the first culture-test 
proved negative. It is not a reliable nor satisfactory method to 
spread membrane or secretion from the throat direct on a cover- 
glass, and decide from such a preparation the nature of the process. 
The technique of culture-tests is scarcely within the scope of this 
work. It is sufficient to state that growth can be obtained within 
four or five hours if the culture-tube is subjected to a temperature of 
100.4° to 102.2° F. (38° to 39° C.) in a small incubator. Other 
diseases, such as membranous forms of stomatitis, may simulate diph- 
theria. In these cases the culture test is the only positive mode of 
making a diagnosis. Certain forms of laryngismus stridulus resem- 
ble acute diphtheritic laryngitis, or a diphtheritic process may be 
present in the larynx in a rachitic infant subject to attacks of 
laryngismus. Cultures should be made in all such cases. 

In small towns and country districts the practitioner without the 
aid afforded by laboratories will often be thrown on his own resources 
in making a diagnosis. In such cases the following clinical symptoms 
may be considered fairly presumptive evidence of diphtheria : 

The presence of membrane on a tonsil and a small patch, streak, 
or speck of membrane on the adjacent surface of the uvula or tip of 
the uvula ; a patch of membrane on the tonsil and an accompanying 
patch on the posterior pharyngeal wall ; the presence of a croupy 
cough and stridulous breathing with small patches of membrane on 
the tonsil or epiglottis, are all of much diagnostic value. The 
presence of albumin in the urine is of little value in making a diag- 
nosis, as it may be present in non-diphtheritic affections and absent 
in diphtheria. Constitutional symptoms are only of corroborative 
value. It is well known that the most virulent forms of diphtheria 
may at first be manifested by few constitutional symptoms. The 
temperature-curve is not characteristic. If a patient who at first suf- 
fers from a catarrhal tonsillitis or pharyngitis, shows within twenty- 
four hours minute patches of membrane either on the uvula or 
pharynx, it may reasonably be assumed that true diphtheria is pres- 
ent. An acute laryngeal inflammation, croupy cough, and stridulous 
breathing which not only persist beyond the first twenty-four hours 
or first night, but also become aggravated, justify a diagnosis of diph- 
theria of the larynx, although no membrane is visible in the throat. 
General symptoms are of little diagnostic value. Rhinitis at first ac- 



356 THE SPECIFIC INFECTIOUS DISEASES. 

companied by a serous and later by a fetid sanguinolent discharge, 
with glandular swellings in the neck, is diagnostic of diphtheria. 

Adenitis is frequently absent at the outset of tonsillar diphtheria, 
even when patches of membrane of some size are present. On the 
other hand, a simple catarrhal tonsillitis is often accompanied by 
marked adenitis. 

Paralysis of the soft palate, appearing in the course of a severe 
or mild pseudomembranous tonsillar, pharyngeal, or laryngeal in- 
flammation, or after the affection has run its course, points strongly 
to true diphtheria, although cases of paralysis of the soft palate 
following diphtheroid have been reported. The color of the mem- 
brane, its detachability, and the fact that a bleeding surface is left 
after its removal, cannot be relied upon as aids to diagnosis, in view 
of the fact that interference with the membrane is not advisable. 

Aphthae with pseudomembrane over the vault of the hard palate, 
spreading to the gums and cheeks, are seen in newly born and older 
infants. These forms of pseudomembranous stomatitis are the result 
of traumatism inflicted by the infected fingers of the nurse or mother, 
and are limited to the parts on which they are first seen. Such septic 
membranes rarely spread unless the exciting causes are perpetuated. 

Herpes of the pillars of the fauces, so-called herpes of the tonsils, 

are often mistaken for diphtheritic patches. With a suitable light 

such an error should seldom be made. 

Following: the ino^estion of caustic alkali or the traumatism con- 
to o 

sequent on washing or rubbing the mucous membrane, aphthous 
ulcerations, which closely simulate diphtheritic membranous patches, 
are prone to appear over the hamular process of the palate bone. 
The history of the case, the absence of diphtheria elsewhere, and 
the result of a culture test will exclude diphtheria. 

The patches of necrotic tissue seen on the tonsils, pillars of the 
fauces, and uvula following tonsillotomy and ablation of adenoids, 
and sometimes accompanied with paralysis, may mislead the observer 
and cause him to make a diagnosis of true diphtheria. 

The membranous patches which appear on the tonsils of scarlet 
fever patients at the outset of the disease are for the most part diph- 
theroid. Unless the patient has been exposed to a double infection, 
which is infrequent in private practice, the patches of membrane 
which appear later in the disease are also of a diphtheroid nature. 
True diphtheria may coexist with scarlet fever (Baginsky, Escherich, 
Councilman), but does so in only a small number of cases. 

The appearance of a pseudomembranous exudate on the tonsils of 
a patient attacked with measles should be regarded as diphtheritic until 
the contrary has been proved. The laryngitis with croupy cough and 
breathing often complicating measles is not, as a rule, diphtheritic. 

The prognosis and mortality vary with the age of the patient, 
the form and severity of the infection, and the extent to which 



DIPHTHERIA. 357 

organs other than the fauces and larynx are involved. Young in- 
fants, unless they come under observ^ation early, give a high mortiality 
rate. Septic forms of diphtheria are more fatal than those in which 
the process is a distinctly local affection. The mortality also varies 
with the nature of the epidemic. In Baginsky's statistics of 2711 
cases, the mortality from the sixth to the twelfth month was 52 per 
cent. ; from the second to the third year, 37 per cent., decreasing to 
8 per cent, in the tenth year. The death-rate is high in infants and 
children of delicate constitution and in those suifering from any 
form of dyscrasia. 

The treatment of diphtheria may be prophylactic, constitutional, 
and local. 

Prophylaxis. — The patient should be isolated as soon as the mem- 
branous deposit is detected. Other children of the family who have 
been in contact with the patient should at once be given immunizing 
doses of antitoxin, and the furniture of the sick-room, such as hangings 
and carpets, should be removed, only the most necessary articles being 
retained. The room should be well ventilated. The nurse should 
not come in contact with other members of the family. All ar- 
ticles of clothing worn by the patient should be dipped in an anti- 
septic solution (corrosive sublimate, 1 : 2000) before removal from 
the sick-room. The physician, before entering the sick-room, should 
cover his head with a cap and wear a long coat or bath-robe, which 
should be hung outside the sick-room. If it is necessary for members 
of the family to enter the room, they should observe the same precau- 
tions, and on leaving the room they should gargle or rinse the mouth 
with some mild cleansing solution, preferably of boric acid. A throat 
culture should at once be made. The swab should be rubbed over 
the tonsils if they are the seat of exudate ; if the case is laryngeal, 
the swab is passed over the epiglottis and posterior pharyngeal wall. 
Utensils used in feeding the patient should not be used by others. 

The patient after convalescence should not mingle with other 
children until culture has proved the absence of the Bacillus diph- 
theria from the throat. 

Constitutional treatment consists first in the administration of 
diphtheria antitoxin. It is not within the scope of this work to 
enter into the details of the theory of action of this agent, which is 
the outcome of the modern experimental method of the investigation 
of disease. Its place in the therapy of diphtheria is now assured. 
The mortality of diphtheria has been greatly reduced since its intro- 
duction. Baginsky gives the following figures, showing the mortality 
before and after the introduction of antitoxin : 

Age. Before. After. 

Two years 60.2 per cent. ; 25.8 per cent. 

Two to four years 51.2 " '' ; 17.1 " " 

Eight to ten years 28.8 '' '' ; 10 " " 



358 THE SPECIFIC INFECTIOUS DISEASES. 

Of 5794 cases in private practice collected by the American 
Pediatric Society, the total mortality was only 12.3 per cent. In 
the cases injected on the first day of the disease the mortality was 
7.3 per cent. In the laryngeal form of diphtheria the results have 
been especially favorable. In 1704 cases operated and not operated 
there was a mortality of 21 per cent., of the intubated cases, 23 
to 27 per cent., as against 60 to 70 per cent, before the introduction 
of antitoxin. 

The DOSAGE varies with the age of the patient, the severity of 
the infection, and the duration of the case before the beginning of 
treatment. Mild forms of local membranous affections of the tonsils 
and pharynx coming under observation on the first day should receive 
doses of antitoxin as follows : Up to one year, 600 units ; one 
to two years, 1000 units ; two to five years, 1500—2000 units. 
If the disease has markedly progressed twenty-four hours after 
the first injection, the initial dose should be repeated. The severer 
forms of localized diphtheria with marked constitutional symptoms 
should receive initial doses half as large again or twice as large. 
Laryngeal forms should receive proportionately large doses. The 
American Pediatric Society recommends as an initial dose 1500 units 
for a child under two years, and 2000 units for one above that age. 
I employ 300 units for immunizing purposes in very young infants, 
and e500 units in older children. 

The immunizing power extends over a period of three weeks. It 
is best to give an initial dose of sufficient amount, so that a repeti- 
tion of the dose will not be necessary ; on the other hand, it is 
advisable not to give an excessively large dose. The concentrated 
antitoxins are preferable both on account of the diminished bulk 
and the infrequency with which skin and joint-affections follow their 
injection. Recently prepared antitoxin should be obtained, for it has 
been shown that this agent deteriorates with age (Abbott), and then 
no longer contains the original unit values. 

Time of Injection. — The antitoxin should be given as early in 
the course of the disease as possible. If membrane is present, no 
time should be lost in waiting for the result of the culture test, for if 
the disease is not true bacillary di])htheria no harm can result from 
the injection, while to wait may be hazardous to the patient. 

Mode of Injection. — The syringe with asbestos packing should 
be used for making injections. Such an instrument is easily cleansed 
and boiled. I find the back just above the buttock the most con- 
venient location in which to inject. The child can be easily held if 
this site is chosen. The parts should be carefully cleansed. The 
injection is given in the same manner as a hypodermic injection. The 
parts should not be rubbed after the injection. 

Effect of Injection. — There is a slight temporary rise of tem- 
perature following the injection. It is thought to be due to the 



DIPHTHERIA. 



359 



entrance into the blood of the additional toxin contained in the 
antitoxin. This rise is succeeded by a gradual or critical fall, which 
continues until the temperature is subnormal. The membrane ceases 

Fig. 56. 




Antitoxin syringe with asbestos packing ; can be taken apart and sterilized. 

to spread and exfoliates. In some cases these phenomena may be 
delayed twenty-four hours. The next day the pulse drops, the pros- 
tration gives way to a clear sensorium and good heart action, and 
sometimes the children sit up in bed and play with toys. The glan- 
dular swelling also diminishes markedly. In laryngeal cases if there 
has been threatened stenosis, the symptoms retrograde. Fully one- 
half retrograde spontaneously. On the other hand, if the temperature 
persists high after twenty-four hours and the membrane continues 
to spread, the injection should be repeated, especially if the swell- 
ing of the lymph-nodes is marked and there are symptoms of septic 
infection. 

The effect of an injection of antitoxin on the blood is to diminish 
the number of leucocytes ; just prior to the fall of temperature there 
is a critical hyperleucocytosis (Ewing, Schlessinger). Albuminuria 
continues, but this is also the case not only when no antitoxin has 
been used, but also in almost any infectious disease in which bacteria 
or their toxins circulate in the blood. 

The eruptions which occur after the injection of antitoxin are of 
interest. At the site of the injection an abscess or phlegmon may 
form. This is the result of uncleanliness in technique or is due to 
some irritating substance in the antitoxin. A brawny erythema 
which gradually disappears may appear in a day or more at the site 
of injection. The injection may be rapidly followed by a painful 
eruption on the extremities, consisting of circumscribed violet colored 
spots, closely resembling erythema nodosum. The subcutaneous 
tissues are swollen, the joints are painful, and in addition there may 
be elevated temperature and a cardiac murmur. Herpes labialis 



360 



THE SPECIFIC INFECTIOUS DISEASES. 



and herpes nasalis, urticaria-like general eruptions, and morbilliform 
or scarlatiniform eruptions have followed injections. These erup- 
tions appear from a few days to fourteen days after the injection. 

Conjunctival injection, tachycardia, and arrhythmia may be present. 

The acute symptoms described above subside in most cases within 
two or three days. 

Kidney irritation may follow the injection of lare^e doses of anti- 
toxin. In many of the cases reported, however, the renal symptoms 
have not been due to the antitoxin alone, and the same may be said 
of the recorded cases of endocarditis following antitoxin injections. 

The introduction of antitoxin has bv no means lessened the 



Fig. 57. 


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RESP. z ■^?,r,wf,W,z\t:\r,^.zzz^^\^f, zzz zzzzzM^rkAtAr^w, t,^,ztaa, ?; 



Septic form of tonsillar diphtheria ; hoth tonsils and soft palate involved with naso- 
pharynx. Persistence of temperature and recurrence of membrane after antitoxin injec- 
tions on the sixth day. Injection of additional antitoxin, and critical drop of temperature 
thereafter. Recovery. Boy, six years of age. 

necessity of careful general management of a case by the physician. 
The temperature is controlled or modified by the ordinary hydro- 
therapeutic procedures. Antipyretics of the coal-tar series should 
not be administered, as they weaken the heart. 

If signs of cardiac paralysis of the early type set in, full doses of 
the cardiac remedies — digitalis (if the pulse is rapid), strychnine, 
caffein, camphor, and whiskey — are given. Of the remedies, digi- 
talis must be used cautiously, else the pulse will be seriously de- 
pressed. Strychnia and caiFein are the best and most available 
remedies. In the cases of cardiac irregularity it is best not to mul- 
tiply drug remedies, or the stomach will be upset and the general 
conditions be aggravated. To a child three years of age we may give 



DIPHTHERIA. 361 

yI^q grain of strychnia every three hours ; whereas caffein is best used 
in the form of the citrate, a grain to a child of three years of age at 
similar intervals. The child is kept recumbent and the most assimi- 
lable forms of food are given, such as milk, kumyss, soft eggs, raw 
or boiled. In those cases in which there is gallop rhythm or ex- 
treme restlessness, digitalis in combination with morphin is given. 
To a child three to five years of age 2 minims of the tincture of 
digitalis may be given every three hours, and 1 or 2 minims of 
Magendie^s solution by the mouth. The latter is repeated only when 
needed. In order to guard against cardiac weakness in the later 
period of the disease, a cardiac stimulant, such as strychnine, is given in 
small doses throughout the illness and in convalescence. The patient 
is not allowed to sit up too early should signs of cardiac irregularity 
appear at the outset of convalescence. In all cases of diphtheria 
the utmost caution should be exercised in reference to the heart. 

The infant should not be nursed at the breast, lest the breast be 
infected. The milk should be pumped off and fed to the infant with 
a bottle. If there is diarrhoea, the milk is suspended and the bowel 
irrigated. The milk should not be resumed until all danger from this 
source is past. I administer alcohol in moderate doses if the pros- 
tration, pulse, and temperature warrant it. Infants under a year 
should be given half a drachm (2.0) of whiskey every three hours ; 
infants more than two years of age, a drachm (4.0) at the same inter- 
vals. Diphtheria patients, especially those suffering from the septic 
form with constitutional symptoms, should be kept recumbent. The 
administration of remedies should not be forced, for struggling on the 
part of the patient may prove dangerous to the heart. During con- 
valescence the whiskey may be replaced by wine. In these cases 
strychnine in small doses (grain -2^-^ [0.0003]) should be continued 
for some time, in order to support the heart. I advise a return to a 
mixed nutritious diet in all cases as soon as the temperature is nor- 
mal ; in this way the effect of the toxins on the tissues is counter- 
acted as much as possible. 

Some physicians still resort to the internal administration of 
corrosive sublimate in doses of grain -^-^ (0.0006) or more, accord- 
ing to the age of the patient. It is given in the septic tonsillar and 
nasal cases, and also in the laryngeal forms of diphtheria. 

Local Treatment. — The presence of bacteria other than the diph- 
theria bacillus around the local lesions necessitates the use of local 
cleansing and disinfecting measures. In very young infants the 
nasal discharges are washed away by means of a glass syringe with 
a blunt rubber tip. The infant is laid on the side, and the nurse, 
standing behind the patient, irrigates the nostrils with normal salt 
solution at 110° F. (43.3° C), as shown in Fig. 9. A pus basin 
is held underneath the chin. Older children will struggle, but by 
suasion they may be irrigated in the sitting posture. If there is much 
resistance, it is not desirable to insist on irrigation. In irrigating. 



362 THE SPECIFIC INFECTIOUS DISEASES. 

the syringe should have a position parallel with the floor of the 
nasal fossae. Spraying with a mild solution of Listerine or DobelFs 
solution is possible in some children, impracticable in others. The 
lymph-nodes, if slightly enlarged, are best treated by the application 
of warm oil of hyoscyamus ; if very much swollen, the application 
of cloths wrung out in ice-cold water is of great utility. Small 
pieces of ice swallowed whole are grateful to the patient. 

Treatment of Laryngeal Diphtheria. — In cases of mild laryngeal 
diphtheria an injection of antitoxin should be given. The patient 
should be placed under a tent, and grains x (0.6) of calomel sublimed 
every two or three hours, according to the necessities of the case. 
The efficacy of the calomel vapor is increased by passing steam into 
the tent at the same time. A convenient method is to place the 
calomel in a spoon, and heat the spoon over an ordinary candle, 
placed within the tent. The swelling of the larynx caused by the 
invasion of the Bacillus diphtherise and other bacteria is quickly 
relieved by the calomel, particularly in croupy cases with little or 
no membrane visible above the larynx. A tent may be improvised 
as described on page 65. Steam saturated with benzoin or thymol 
may also be passed into the tent. A croup kettle may be improvised 
from an ordinary teapot or one sold for the purpose may be em- 
ployed. It is sometimes necessary to suspend the steam inhalations 
for an hour or longer, for the purposes of ventilation. The general 
treattaent as to the heart, temperature, and food is the same as in 
the tonsillar forms of diphtheria. If signs of mechanical obstruction 
appear, intubation is indicated. 

Intubation. — To Joseph O'Dwyer, of New York, belongs the 
credit of having perfected a method of relieving membranous ob- 
struction of the larynx in diphtheria. Intubation in America and 
on the continent of Europe has completely displaced tracheotomy as 
a remedy for relieving laryngeal obstruction due to diphtheria. 

Instruments. — Intubation tubes (Fig. 58) are of metal coated with 
rubber, though originally made of gilt metal. The tubes are grad- 
uated (Fig. 59) according to the 
Fig. 58. age of the patient, and in their Fig. 59. 

present form are the most inge- 
niously devised instruments ever 
ffiven bv American medicine to Gauge for the age of the 

O c T)RtlGIlt. 

the world. The tubes are fur- 
nished with obturators, which fit into a handle, the in- 
o'Dwyer tube, troduccr (Fig. 60). There is, in addition, a forceps 
(Fig. 61) with small departing blades, called the ex- 
tractor. Finally, there is a gag (Fig. 62) so constructed that it 
may be introduced into the mouth and kept in position without 
obstructing the view of the operator. 

Indications. — We intubate when a progressive dyspnoea, which 



DIPHTHERIA. 

Fig. 60. 



363 




O'Dwyer tube, obturator, and handle. 
Fig. 61. 




The O'Dwyer extractor. 
Fig. 62. 




Gag of the O'Dwyer set. 



364 



THE SPECIFIC INFECTIOUS DISEASES. 
Fig. 63. 



'■^ iBfe... - 






J 











Introduction of the tube along the index finger. 



Fig. 64. 




Passing the tube over the epiglottis. 

Figs. 63, 64.— The operation of intubation of the larynx. Position of child, operator, and 

assistant. 



DIPHTHERIA. 
Fig. 65. 



365 




Introduction of the tube into the chink of the glottis. 
Fig. m. 




The index finger pushes the head of the tube into place in the larynx. 

Figs. 65, 66.— The operation of intubation of the larynx. Position of child, operator, and 

assistant. 

produces sensible exhaustion, exists. O'Dwyer never tubed the 
larynx except as a dernier ressort, and did not approve of early 
tubage. If an infant or child shows marked retraction of the supra- 



366 



THE SPECIFIC INFECTIOUS DISEASES, 



sternal notch, retraction of the epigastrium, and stridor, with accom- 
panying labored breathing, we should at once proceed to tube the 
larynx. 

Ifode of Operating. — The patient is wrapped in a blanket and 
held upright in the arms of a nurse, so that the head of the patient 
is on a level convenient to the operator, who stands facing the 
patient. An assistant standing behind the nurse steadies the head 
of the patient. The gag is introduced by depressing the tongue and 
jaw with a tongue-depressor. The assistant steadies the gag as he 
holds the head tilted very slightly backward. The tube, threaded 
with a silk ligature, is with its introducer held firmly with the right 
hand. The index finger of the left hand is now introduced into the 
mouth to the root of the tongue and search made for the epiglottis. 
In young infants ^ the epiglottis is short. The finger must be intro- 
duced quite deeply, feeling the arytenoid cartilages of the larynx, 
and is then drawn upward until the epiglottis is hooked forward. 
The index finger now holds the epiglottis (Fig. 67), and in a small 

Fig. 67. 




Method of hooking forward the epiglottis in intubation. 

larynx a skilled operator can also feel the arytenoids (Fig. 68). The 
tube is now introduced in the median line of the mouth along the 

^ Peculiarities of the Larynx. — Thomson and Turner have shown that the infantile 
form of larynx differs materially from that found later in life. At birth and in infants 
and young children the epiglottis is very small and gutter-shaped. The glottis 
is guarded above by the aryteno-epiglottic folds, which are closely approximated 
to each other. Toward the tenth year the epiglottis becomes much flattened, the 
aryteno-epiglottic folds become widely separated, and the larynx assumes the adult 
type. It is important to remember these points in the operation of intubation. 



DIPHTHERIA. 



367 



palmar surface of the index finger (Fig. 63), and the finger guides 
the tube over the epiglottis and into the chink of the glottis and 
prevents its slipping into the oesophagus (Fig. 64). The instru- 
ment should always be kept in the median line. The index 
finger holding the epiglottis should be held well to the angle of 
the mouth, so as to obtain plenty of room. No force should be 
used, else false passages will be made. If the first attempt at 
introduction does not succeed, we should not persist too long, but 
remove the introducer rapidly and give the larynx a few moments 
to recover its action, and then try again. As the tube passes into 
the chink of the glottis the handle of the introducer is elevated, as in 
Fig. 65, causing the end of the instrument to lie against the base of 
the tongue. The tube is released, the introducer and obturator with- 
drawn, and the index finger gently presses the head (Fig. 66) of the 
tube into the larynx. The gag is withdrawn, and the silken thread 
passed over the ear of the patient and fixed back of the ear with a 
piece of rubber plaster. Some operators remove the thread after ten 
minutes. The advantages of leaving the thread are that, should the 
tube be coughed up in the absence of the physician, it can be recov- 
ered by the nurse. In extubating, it is an aid in removing the tube. 
!No anaesthetic is required, and ordinary assistance only is neces- 
sary. The air passing into the bronchi is moistened in its passage 
through the natural passages. The danger that food particles may 
pass into the larynx has been exaggerated. The detachment of mem- 
brane in front of the tube is very infrequent. Should it happen, 
and the membrane not be expelled on removal of the tube, tracheotomy 
is admissible if asphyxia is imminent. It sometimes happens that 
the tube is expelled many times after introduction. It should be 
reintroduced or a larger tube employed. 

Fig. 68. 
12 3 




The infantile larynx. Its development into the adult type at the ap:e of nine years. 1. 
Infant, three months of age. 2. Child, three and a half years of age. 3. Boy, nine years of 
age. Enlargement upward of the epiglottis and shaping of the arytenoid cartilages. 
(Thomson and Turner, British Medical Journal, December 1, 1900.) 



368 THE SPECIFIC INFECTIOUS DISEASES. 

If the operator has chosen to leave the silken cord of the tube in situ, it 
should be passed through the space between the first molar and bicuspid tooth, 
to avoid its being gradually bitten through. Should it be bitten through, the 
finger is introduced into the mouth to the top of the tube and the thread with- 
drawn, while the tube is kept in the larynx with the finger. 

The tube is allowed to remain from twenty-four hours to five 
days. Since the introduction of antitoxin the tube is taken out 
much sooner than was formerly tlie practice. If there is marked 
improvement in two or three days, removal of the tube should be 
attempted and the effect of such a procedure on the breathing 
should be observed. 

Extahation. — The patient is placed in the same position as for 
intubation. The left index finger is passed into the mouth and 
search made for the epiglottis, the tip of the finger resting on the 
arytenoids. The extractor is passed along the palmar side of the 
finger and is guided into the opening in the tube by the tip of the 
finger. Extubation is more difficult than intubation. The ex- 
tractor should be regulated by means of a small screw, so that the 
blades do not open too far. This is to guard against injury to 
the soft parts of the larynx should the opening of the tube not be 
entered. 

Dangers. — The dangers of intubation include detachment of 
membrane during introduction, laceration of the parts, the forma- 
tion of false passages, and asphyxia. The first rarely occurs unless 
force is used. The second can only occur as a result of rough and 
unskilled efforts at intubation. The third occurs only following 
prolonged efforts at introduction of the tube. Even a skilful oper- 
ator may pass the tube into the ventricle of the larynx. Northrup has 
published a case in which there was a false pocket above the cords 
which prevented the entrance of the tube into tlie larvnx. In other 
cases there is what is described by O'Dwyer as subglottic stenosis. 
Northrup thinks that this is due to swelling of the mucous membrane 
at the level of the cricoid cartilage. In these cases introduction of 
the tube is very difficult. The operator may be compelled to use 
force to push the tube past the stenosis or a smaller tube may be 
employed. While the tube is being worn, it may become obstructed 
by membrane. This is denoted by a return of the croupy cough, a 
snarling, flapping sound, and obstruction to expiration. To obviate 
these difficulties, O'Dwyer has had short tubes constructed without 
a retaining flange. These tubes have a special introducer. The 
largest size for the age is chosen, and the tube forced into the 
larynx. These tubes should be used only by skilled operators. The 
tubes are allowed to remain but a short time in the larynx. Other 
complications are the formation of granulations or ulcerations around 
the lower end of the tube if it is too long, and at the cricoid cartilage 
if it is too large. The former condition is not serious ; the latter may 



DIPHTHERIA. 



369 



Fig 




Built-up tubes. 



destroy the cartilage. Granulations may form about the head of the 
tube. In this case tubes with built-up heads are used to press on the 
granulations, thus causing them to atrophy (Fig. 69). 

Feeding the patient after introduction of the tube requires care. 
Most infants will nurse with the tube in the larynx. In some there 
is considerable difficulty in swallowing. The 
patient is taken in the lap of the nurse and fed 
with the head held a little lower than the body. 
Fluids thus cannot enter the trachea and cause 
pneumonia. 

Treatment of the Complications. — The treat- 
ment of the BRONCHO-PNEUMONIA which com- 
plicates diphtheria is similar to that employed 
in the treatment of the primary affection. The 
question of the further administration of anti- 
toxin always arises in these cases. I give it 
in full doses, since it is known that the 
Bacillus diphtherise is the causative factor. 

The GASTRO-ENTERiTis which complicates 
diphtheria is apt to prove a very serious com- 
plication. It should receive the same treat- 
ment as a primary gastro-enteritis. 

Both the severe and the mild cases of 
diphtheria of the vulva or of the vulva and vagina should be 
treated with antitoxin. In some of the mild forms of undoubted 
bacillary origin which I have seen, the membrane was easily remov- 
able. In these cases, contrary to the practice in the tonsillar cases, 
I remove the membrane with a spud wrapped with cotton.^ The 
bleeding surface left after removal is painted with a 10 per cent, 
solution of silver nitrate once daily. I have cured cases by this 
method alone. If there are extensive swelling, necrosis, and gan- 
grene, this method will be of no avail, and antitoxin should be 
given in full doses, and repeated according to indications. 

Paralyses. — The treatment of diphtheritic and especially post- 
diphtheritic paralyses is at present largely empirical. The symptoms 
appear with the degenerations in full progress. Of all the remedies 
recommended, Fowler's solution in tonic doses has seemed to give 
the best results. I have seen patients recover Avhen given arsenic, 
nutritious food, and abundant fresh air. Hypodermic injections 
of strychnine are of questionable value. Electricity is of value 
as an adjuvant to massage of the muscles only in general paralysis. 
It is questionable whether in some cases it is not capable of doing 
great harm by tiring nerve and muscle. I find that patients do very 
well with hydrotherapy and massage. In these cases the last reac- 
tion to reappear is the patellar reflex, 



84 



370 THE SPECIFIC INFECTIOUS DISEASES. 

Diphtheroid. 

(Pseudodiphtheria ; False Diphtheria.) 

The term diphtheroid includes all pseudomembranous formations 
not caused by the Klebs-Loffler bacillus. It was first proposed in 
1860 by Boussage, and has recently been adopted by Weigert, Esch- 
erich, Heubner, and Behring. 

Occurrence. — This form of pseudomembranous formation is 
most frequently met with in the exanthemata, especially scarlet fever 
and measles. In the former it is a common complication. It is 
also met in other conditions, and fevers such as typhoid, and may 
occur as a primary affection. 

Etiology. — The cases met in the exanthemata were first de- 
scribed by Prudden, who believed that the process was due to a 
streptococcus, the Streptococcus diphtherise. Since then, the occur- 
rence of the streptococci has been confirmed, but there have also 
been added to this group of pseudomembranous inflammations cases 
in which the pseudomembrane is caused by a diplococcus, the so- 
called Roux coccus. The pneumococcus (Jaccoud and Menetrier) 
may also cause a pseudomembranous angina. The Bacterium coli 
ancl the gonococcus (the latter in newly born infants) may cause a 
membranous formation in the mouth and throat. The Staphylo- 
coccus pyogenes aureus is also found in these diphtheroid mem- 
branes. By far the most important group is that first mentioned, 
the pseudomembranous or diphtheroid inflammation caused by the 
Streptococcus pyogenes, which is none other than that isolated by 
Prudden. These cases are characterized by their favorable course ; 
while the mortality in diphtheria varies from 20 to 35 per cent., 
according to the age of the patient, the virulence of the epidemic, 
and the early administration of antitoxin, the mortality of the 
diphtheroid cases ranges from 3 to 5 per cent. (Park, Baginsky). 

Symptoms and Course. — The pseudomembrane occurs on the 
tonsils, pharynx, and larynx. There are adenopathy and fever. 
The prostration and constitutional disturbance are much less than 
in true diphtheria. Membranes and casts of the larynx and trachea 
may be expelled. Suppuration of the lymph-nodes may also occur. 
In many of these cases there is a complicating bronchopneumonia 
of the streptococcus type (Prudden and Northrup), which usually 
results fatally. 

Diagnosis. — It is not possible to make a diagnosis of diphthe- 
roid from the gross appearance of the membrane. The culture-test 
is the only reliable method of determining the nature of a pseudo- 
membranous exudate. If the first culture gives a negative result, a 
second one should be made. 

Treatment. — Clinically the treatment is much the same as in 
true diphtheria. The administration of antitoxin should not be 
delayed until the nature of the exudate is determined. It is then 



SCROFULA OR SCROFULOSIS, 371 

discontinued. An exception to this rule may be made in the scar- 
latinal form of diphtheroid, in which it is safe to wait for the result 
of the culture-test, unless it is known that the patient has been ex- 
posed to diphtheritic infection. In such a case antitoxin should be 
administered. In laryngeal obstruction the indications for treatment 
are the same as in true diphtheria. 

XVI. SCROFULA or SCROFULOSIS. 

Scrofulosis is a constitutional dyscrasia which occurs chiefly in 
childhood, and is characterized by enlargement of the lymph-nodes 
and slow, sluggish inflammation of the mucous membranes, skin, 
joints, and bones. There is a distinct tendency to repeated inflam- 
mations from very trivial causes. 

Occurrence. — Scrofulosis is almost exclusively a disease of child- 
hood and youth, and is rarely seen after the twentieth year. Henoch 
and Birch-Hirschfeld state that the majority of cases occur between 
the third and the fifteenth year. Females are more frequently affected 
than males. Ruhl found it to be most common between the sixth 
and the tenth year. 

Forms. — Cornet and Ponfick recognize three forms of scrofulosis : 

a. The tuberculous form, which is practically identical with 
cutaneous, lymphatic, and bone tuberculosis. 

6. The pyogenic form, in which the tubercle bacillus is absent 
in the lesions or products of inflammation, but which in its outward 
clinical manifestations closely resembles the tuberculous form. In 
this form the essential etiological factors are the Staphylococcus 
pyogenes aureus and albus and the Streptococcus pyogenes. 

c. The mixed form, in which both the tubercle bacillus and the 
pyogenic bacteria are found in the lesions and products of inflam- 
mation. 

Etiology. — In considering the etiology of scrofulosis, it should 
be borne in mind that at the period of life during which the disease 
occurs the lymph-nodes are not structurally fully developed. On 
account of this condition and of deficiencies of other tissues such 
as the skin and mucous membranes, bacteria obtain easy access 
through the skin, mucous membranes, and lymph-vessels even when 
there is no breach of continuity of surface (Cornet). 

It is also true that certain individuals, once infected, show an in- 
herited predisposition to affections of the mucous membranes and 
other tissues. This does not mean that scrofulosis as such is hered- 
itary, but that in these subjects exposure to the essential causes of 
the disease will result in permanently establishing the conditions. 

The essential causes of scrofulosis are the tubercle bacillus and the 
pyogenic bacteria just mentioned. These bacteria are present in ill- 
ventilated rooms occupied by phthisical patients. Scrofulous infection 



372 THE SPECIFIC INFECTIOUS DISEASES. 

may be traced to parents, brothers, sisters, nurses, and playmates. 
Dried sputum is a prolific source of infection. Infection is favored 
by any solution of continuity of the skin or mucous membranes, and 
also by hypersemia or oedema of these tissues. 

The predisposing factors are social conditions, unhygienic sur- 
roundings, moist dark dwellings, uncleanliness, improper or insuffi- 
cient food, and lack of fresh air and exercise. The overcrowding in the 
poorer quarters of cities affords abundant opportunities for infection. 
Any weakening of the system by infectious diseases, such as measles, 
pertussis, scarlet fever, diphtheria, rachitis, struma, cretinism, and 
erysipelas, may be the starting-point for infection. Traumatism or 
frostbite favors the entrance of bacteria. 

Morbid Anatomy. — The gross pathological changes are the same 
in both the pyogenic and tuberculous forms of scrofulosis. 

The Pyogenic Form. — The mucous membranes are the seat of 
hypersemia and thickening. There are increased secretion and 
activity of the glands, also desquamation of epithelium, and excretion 
of serum and blood-elements from the surface of the membrane. 
Adenoids, enlarged tonsils, bronchitis, intestinal and vaginal catarrh, 
are the most common of the lesions of the mucous membrane. 

Skin. — There are eczema, thickening of the epidermis, and tran- 
sudation of serum and elements of the blood (erythrocytes and 
leucocytes). 

The CORNEA shows conjunctivitis and phlyctenulse. 
The LYMPH-NODES show hyperplasia, which is scarcely noticeable 
in the early stages. They subsequently enlarge to form tumor 
masses, which may soften as a result of suppuration or may retro- 
grade to the normal. 

The Tuberculous Form. — Skin. — Lupus is the form of change 
found in the skin. 

Lymph-nodes. — The nodes in almost any part of the body may 
be involved. They are enlarged to a greater or less degree, and are 
infiltrated with tubercle. On section they show either simple case- 
ation or mixed infection. The latter is the case if pyogenic infection 
is combined with the tuberculous form. Nodes which are the seat 
of cheesy degeneration may soften and break down, forming cold 
abscesses. These may open externally or into the bronchi, blood- 
vessels, pericardium, or peritoneum. 

Joints and Bones. — In the bones the tuberculous invasion 
gives rise to fungus or dry caries. Several such foci may be present 
in the same bone. These foci may heal and years afterward become 
inflamed as a result of traumatism or infectious disease. 

The fingers, toes, and extremities of the long bones are thickened 
as the result of periosteal inflammation. The ends of the bones are 
the seat of tuberculous osteomyelitis. The joints may be involved. 
At first there is serous exudate without perforation into the joint 



SCROFULA OR SCROFULOSIS. 373 

of the tuberculous foci. Later there are thickening of the synovial 
membranes and seropurulent exudate into the joint-cavity, with 
destruction of the cartilages and heads of the bones. 

Symptoms. — General Clinical Picture. — The patient is anaemic, 
but not necessarily emaciated ; on the contrary, there is a very good 
panniculus of fat in the majority of cases. The face of some of these 
subjects presents an eczematous or lupoid eruption. The lips are 
thick ; the conjunctivae may be injected, and there may be blepharitis 
or phlyctenula of the cornea. Snuffles and nasul catarrh or ozaena 
are present. The majority of the patients are mouth-breathers, 
and suffer from adenoids and enlarged tonsils. In some there is 
chronic otitis with an offensive discharge. There is a fulness about 
the neck due to enlarged lymph-nodes. The body may present skin 
eruptions in the form of ecthyma or varieties of eczema. The gen- 
eral surface is in other cases free from eruption, is pale, and has a 
transparent, marble-like appearance, showing the blue veins under- 
neath. Many of these patients give a history of chronic bronchitis. 
In others the remains of old suppurations of the lymph-nodes about 
the neck are seen in the form of livid cicatrices. If the long bones 
of the extremities have been affected, the surface of the skin shows 
either old or recent bone sinuses. The symptoms in most cases 
develop first on the skin and mucous membranes ; the lymph-nodes 
then enlarge, the bones and joints are next involved, and finally, if 
the case does not progress favorably, amyloid degeneration of the 
different organs and emaciation develop as a result of prolonged sup- 
puration. In all cases the changes in the lymph-nodes play a leading 
part, and are characteristic. 

The Skin. — In the tuberculous variety lupus is the most com- 
mon form of skin lesion ; in another form there is the so-called 
scrofuloderma of Besnier. Lichen scrofulosorum, with the character- 
istic enlargement of the lymph-nodes, is another form of skin erup- 
tion. In the pyogenic variety eczematous and acneform eruptions 
are present. In such cases the skin is thickened as a result of 
chronic inflammations. There are suppurating rhagades around the 
eyes, mouth, and anus, and ecthymatous eruptions may be present 
on the trunk and extremities. A form of scrofulous ecthyma, made 
up of purple painful nodules resembling erythema nodosum, has 
been described by Hutchinson. Hebra has described a prurigo of 
the scrofulous subject. 

Mucous Membranes. — There are ulcerations and chronic catarrh 
of the nasal and bronchial mucous membranes, and in some cases 
ozsena of an atrophic character. These patients have adenoids and 
enlarged tonsils. The tonsils are favorite seats of infection. In 
other cases the posterior nasal and pharyngeal catarrh leads to retro- 
pharyngeal abscess, or caries of the spine may cause abscess forma- 
tions in the retropharynx. 



374 THE SPECIFIC INFECTIOUS DISEASES. 

The Ears. — As a result of the catarrh of the nasopharynx 
chronic otitis may develop. When otitis follows any of the exan- 
themata in a patient with scrofulous tendencies, it pursues a chronic 
painless course. Such an otitis may tend to tuberculous disease of 
the mastoid with sinus thrombosis, or even to tuberculous meningitis. 
There is pain only when there is a mixed pyogenic infection. 

The Eye. — Chronic eczema of the Uds, blepharitis, phlyctenula 
of the cornea, and keratitis fasciculosa are seen. The phlyctenulse do 
not yield readily to treatment. Hypopyon of the anterior chamber 
may also be present. Trachoma is in some instances of a tubercu- 
lous origin. Lupus of the conjunctiva is sometimes present. 

Lymph-nodes. — The tuberculous and pyogenic forms of enlarge- 
ment of the lymph-nodes are at the outset similar. The pyogenic 
varieties are associated with enlarged tonsils and adenoids. The 
skin over the enlarged nodes may remain normal for months or 
years, or in both the tuberculous and pyogenic varieties it may 
become adherent, red, inflamed, and break down. The lymph-nodes 
discharge, leaving suppurating cicatricial openings. 

Clinically, infections of the scalp lead to enlargement of the 
lymph-nodes of the neck and retromaxillary region. Those of the 
cornea, iris, and ear tend to enlarged preauricular nodes and to en- 
larged nodes of the submaxillary region. Infections of the mouth 
and tonsil cause enlarged nodes at the angle of the jaw and beneath 
it. Otitis with mastoid disease causes enlargement of the node on 
the point of the mastoid. The lymphatics of the gums and lips are 
connected with the nodes of the submaxillary region and angle of the 
jaw. Affections of the nose will cause enlargement of the glands 
of the neck (Jacobi). Lesions of the fingers will result in enlarge- 
ment of the cubital and axillary nodes. Infection of a circum- 
cision wound or balanitis will cause enlargement of the inguinal 
lymph-nodes, as will also infections of the foot and knee. 

The lymph-nodes in direct line are always involved ; distant ones 
are never infected unless there is infection of the intermediate nodes. 
It was formerly believed that the bronchial nodes w^ere particularly 
subject to infection. Any special susceptibility to infection shown 
by these nodes is due to their location, infectious material being fre- 
quently present in their vicinity. 

Cornet found the bronchial nodes affected in 103 out of 126 
cases of tuberculous disease occurring before the completion of the 
fifteenth year. These observations confirm the statement of Henoch, 
that the bronchial nodes are affected in the majority of cases of 
tuberculous disease. There are no statistics showing the involve- 
ment of lymph-nodes in the pyogenic forms of scrofulosis. Becker, 
Barthez and Rilliet, Henoch, and Northrup have described the 
enlargement of bronchial nodes. According to Henoch, they may, 
even if tuberculous, be enlarged without involving the lung tissue. 



SCROFULA OR SCROFULOSIS. 375 

By pressing on the vagi they may cause rapidity of pulse, and if 
on the recurrent laryngeal may give rise to spasmodic dyspnoea or 
to a croupy cough. Pressure on the oesophagus may cause dysphagia ; 
pressure on the trachea may cause inspiratory dyspnoea ; and pressure 
on the pulmonary veins, hypersemia of the lungs. Henoch and 
Baginsky doubt the possibility of diagnosing these enlarged nodes 
even with the help of all these symptoms. 

These nodes may retrograde to the normal size (West) or they 
may break down and perforate into a bronchus or the trachea. If 
they perforate into the pericardium, pleura, or mediastinum, inflam- 
mation results at these points. 

The mesenteric lymph-nodes may enlarge and cause pain or 
tuberculous infection of the peritoneum (tabes meseraica). In some 
cases they may be palpated through the abdominal wall. 

Fig. 70. 




Tuberculosis of the proximal phalanx of the index finger in a scrofulous child the subject 
of extensive lupus of the face and extremities (" Spina ventosa"). 

The Bones and Joints. — The extremities of the long bones are 
most frequently the seat of disease ; the diaphysis rarely so. The 
phalanges of the fingers, the toes, the radius, the ulna, and fibula, 
are affected in the order of naming. The joint-cavities may at first 
contain exudate without perforation of the cartilage ; later, pus is 
found in the cavity. 

All of the structures of the joint are involved, and the joint 
may eventually be destroyed. Suppuration of a chronic nature may, 
as stated elsewhere, tend to amyloid degeneration' of the liver and 
spleen. 

There is, in addition, a progressive anaemia. The temperature 
is sometimes raised a half or three-quarters of a degree above the 



376 THE SPECIFIC INFECTIOUS DISEASES. 

normal, at others it is normal. Exhausting sweats occur ; the dis- 
turbances of nutrition become in some cases extreme. There may be 
intestinal diarrhoea. 

Course and Prognosis. — This condition is not necessarily fatal. 
Many cases make a good recovery under proper management. This 
is particularly true of the pyogenic form. The tuberculous variety 
may also retrograde if the disease be localized to certain lymph- 
nodes or bone foci. 

Diagnosis. — The diagnosis of the pyogenic form is made from 
the clinical history ; that of the tuberculous variety, either from the 
presence of the tubercle bacillus in the pus or lesions of the disease. 
There are mixed forms in which it is not always possible to decide 
whether the process is tuberculous or pyogenic. The clinical history 
and blood examination will be of service in differentiating scrofu- 
losis from leukaemia, pseudoleuksemia, and lymphomata of a malig- 
nant nature (Plate XIII.). In other cases the diagnosis from 
late forms of hereditary syphilis cannot always be readily made. 
The history of such cases is of irhportance. In many cases a 
resort to antisyphilitic treatment will be necessary to complete 
the diagnosis. 

The treatment of scrofulosis is directed toward limiting if 
possible the spread of the infection, preventing reinfection of the 
patient, and instituting local treatment of the lesion. In order that 
the disease may be treated successfully, the patient should be placed 
under hygienic surroundings. If the patient is in the city, removal 
to the country is advisable. The food should be plain and nutritious ; 
milk, eggs, meat, vegetables, and cereals should form the diet. The 
hygiene of the skin is important. Alkaline or sea baths give tone to 
the skin. Moderate exercise in the open air is also of great service 
in correcting the ansemia and tendency to inaction shown by these 
patients. In a word, the patient should be removed from the con- 
ditions and surroundings which originally induced the infection. 

The medical treatment is limited to the exhibition of such tonics as 
iron. Fowler's solution, and strychnine. The intestines should receive 
attention during the administration of iron. Fowler's solution gives 
better results in pyogenic lymphadenitis than in the tuberculous form. 
The syrup of ferric iodide in full doses has a tonic effect on the 
mucous membranes. Baginsky advises the exhibition of preparations 
of thyroid gland. I have not seen any markedly good results 
obtained by this method of treatment. 

Cod-liver oil is of great value in this disease. In the form of 
emulsions it should be given in full doses ; with young children its 
use must sometimes be suspended on account of the laxative effect 
on the intestines. 

The local skin lesions should receive appropriate treatment, as 
should also the bones, joints, and suppurating lymph-nodes. It is not 



PLATE XIIL 




Multiple Lymphosareomata as Differentiated from Scrofulous 
Lymphadenitis. Enlargement of the cervical, supraclavicular, 
and axillary lymph-nodes. Child six years of age. 



TUBERCULOSIS. 377 

Within the province of this work to enter upon the surgical details 
of such treatment. 

XVII. TUBERCULOSIS. 

Etiology. — The essential cause of tuberculosis is the tubercle 
bacillus. This micro-organism gains entrance to the body through 
the respiratory channels (inhalations), the intestinal canal, and 
through wounds. The air in ill-ventilated rooms occupied by tuber- 
culous individuals may at times contain the bacillus in particles of 
dried sputum. Any abrasion of the mucous membrane of the res- 
piratory tract affords opportunities for the entrance of the bacillus 
into the blood and lymph-channels. Among cases of this kind 
belong those in which phthisical individuals have breathed into the 
mouths of asphyxiated infants or children. 

I^ot much importance is attached by certain authors to the possi- 
bility of infection through the intestinal canal (Baumgarten, Boll- 
inger). However, cases have been reported in which infected cows' 
milk has caused tuberculosis in infants (Leonhardt, Sonntag, Eber). 
Infection in this manner is rare, because the food of infants (milk) 
is as a rule heated before it is taken into the stomach. 

In a recent monograph Blackader says that of 125 autopsies on 
tuberculous children Northrup found that in 88 cases the primary 
infection had occurred through the respiratory tract. In 3 cases the 
pathway of infection was the intestinal canal, and in 35 cases the 
primary seat of infection remained undetermined. Of 75 additional 
autopsies, Bovaird found the primary lesion in the lungs or bronchial 
nodes in 60 cases. English writers, according to Blackader, place 
the frequency of primary infection through the intestinal tract 
at a much higher figure (25 to 30 per cent.) than do American 
investigators. 

Still, of Great Ormond Street, gives the following statistics of 
primary tuberculosis in infants and children : 

Lung ^^^ \ 138 1 

Probably lung . . . . .... 33 / I 153:^57 per cent. 

Probably ear 6 / j 

Intestine 53 1 ao oo a * 

Probably intestine 10 | 63=23.4 per cent. 

Bones, etc 5 



} 



Fauces 2 \- 53=nearly 20 per cent. 

Uncertain 46 

German pathologists maintain that primary tuberculosis of the 
intestinal canal is rare. Marfan, the French pediatrist, places the 
frequency of primary intestinal tuberculosis at 87 per cent. 

In general, it may be said that the avenue of infection in infants 
and children is through the respiratory tract. Infection through 
infected milk is now believed to be very rare. The importance 



378 THE SPECIFIC INFECTIOUS DISEASES. 

of this mode of infection has been heretofore much exaggerated 
(Blackader). 

Infection through mother's milk has been recorded as occurring 
in the newborn infant (Roger and Garnier). Heredity only creates 
predisposition to the disease, as it does with adults. Dennig found 
that 58 per cent, of his cases of tuberculosis occurred in children of 
tuberculous families. 

Infection through wounds is very uncommon with children, be- 
cause they are not usually exposed to traumatism. It is not so 
likely to result in general tuberculosis as infection through the other 
channels. This is proved by the fact that in the adult so-called au- 
topsy tubercle rarely tends to general infection. Infants who are 
subjected to ritual circumcision are exposed to infection through the 
practice of arresting the resulting hemorrhage by mouth suction. 
I have seen eight instances of such infection. In these cases there 
is a primary enlargement of the inguinal lymph-nodes before the 
process becomes general. The vertebrse may become tuberculous 
or meningitis of a tuberculous nature may result. 

The infectious diseases play an important role as predisposing 
factors in tuberculosis. Measles, scarlet fever, pertussis, and influ- 
enza, by lessening the resistance of the economy and impairing the 
integrity of the air-passages, favor the infection. Tuberculous 
bronchopneumonia occurs under these conditions, either because the 
tubercle bacillus was present in the body before the infection was 
contracted or gained access subsequently (Frankel). In the majority 
of cases the former condition is the rule. Cold, unhygienic sur- 
roundings, and poor food, all predispose to infection as with adults. 

Foetal Tuberculosis. 

Foetal tuberculosis is rare, but undoubted cases are recorded in 
the literature. Jacobi's case was that of a seven months' foetus 
born of a tuberculous mother, which showed miliary tuberculosis. 
Including this, there are 6 cases of undoubted foetal tuberculosis 
recorded in the literature (Jacobi, Birch-Hirschfeld, Lehman, 
Schmorl, Kockel, and Wollstein). In all these cases the mode of 
infection was by way of the placenta. 

Of the cases occurring in very early infancy and the newborn, very 
few exist in the literature which may be traced to intrauterine infection, 
and are therefore to be considered as congenital. In these cases the 
children died so soon after birth, and the lesions were so far advanced, 
as to justify this assumption. Tubercle bacilli are exceedingly rare 
in the testis or sperma, and it is questionable whether in such cases 
a tuberculous foetus can result. In the human subject there is not 
one authentic example of infection through the sperma of a tuber- 
culous individual. Among animals we find that there are many 



FCETAL TUBERCULOSIS. ' 379 

cases of observed intrauterine infection ; but no cases in the human 
subject of infection brought about by insemination of the male. 
There are 70 cases in animals, which have been carefully sifted, 
of foetal tuberculosis of the congenital variety. In all the avenue 
of infection was by way of the placenta. In no case was the ovum 
primarily infected or the germinative infection traced to the father. 
True congenital tuberculosis, therefore, in the sense just intimated, 
is rare. Foetal tuberculosis occurs, as shown above, but is not 
such an important mode of infection for so widespread a disease 
as tuberculosis. 

There is another form of foetal tuberculosis, and that is the 
so-called bacillosis or bacillary form. In this form the foetus is 
found to be free from the lesions of tuberculosis, but bacilli are found 
in the umbilical vein or in the liver or in the foetal organs. Such 
are the cases, including that of Bugge, of foetal tuberculosis without 
lesions. The rarity of the tuberculosis of the foetus is due to the 
fact that bacillosis of the mother is rare. Bacilli occurring free in 
the circulation in advanced phthisis is rare in itself; and they 
soon become localized in the tissues. The placenta, as also the 
liver of the foetus, acts as a barrier and filter of the tubercle bacilli, 
or they die in the blood-stream. Another reason, as stated, is the 
rarity of congenital lesions of the mother whereby the ovum may 
be infected. 

The characteristics of foetal tubercle are : (1) That it is rarely 
pulmonary. The liver is frequently affected, also the spleen, kid- 
neys, and suprarenal capsules ; whereas in the lungs only isolated 
tubercles are found. (2) Foetal tissues are a favorable soil for tuber- 
cle. (3) Giant cells are wanting. (4) Bacilli may be present in 
large numbers without the development of gross lesions (bacillosis 
without lesions). 

Under placental infection are to be included those cases in which 
the tubercle bacillus has been found in the blood of the foetus with- 
out accompanying changes in the organs (Schmorl), and those in 
which tubercle nodules and enlarged lymph-nodes have been found 
at birth (Landouzy and Lehman). In both these forms of tubercu- 
lous infection the mother had suffered from acute miliary tuber- 
culosis. The spermatozoon and testis may contain tubercle bacilli 
in the absence of gross tuberculous lesions of the organ (Nakarai 
and Kockel). Tuberculosis may in this way be conveyed into 
the uterus at the time of conception. Jahni and Weigert found 
tubercle bacilli also in the Fallopian tubes of women dying of phthisis, 
although there were no gross changes in the tubes. The ovum may 
thus convey tubercle bacilli. As a rule the bacilli thus introduced 
into the ovum of the foetus are dormant during intra-uterine life. 
They may develop at any period after birth (Baumgarten). Addi- 
tional facts supporting the theory of intra-uterine infection of the 



380 TBE SPECIFIC INFECTIOUS DISEASES. 

foetus have been reported by Baumgarten and Roloff, who found 
a cheesy nodule in a dead-born foetus, and by Birch-Hirschfeld and 
Bugge, who found bacilli in the blood of a foetus born of a tubercu- 
lous parent. 

The frequency of the occurrence of tuberculosis in infancy and 
childhood varies with the environment. Statistics are therefore only 
relative. Seidl found that of 646 consecutive autopsies upon chil- 
dren, 14 per cent, were tuberculous. Forty-five per cent, of all the 
cases of tuberculosis occur during the first two years of life, 25 per 
cent, of the total number occur during the first year, and 71 per 
cent, during the first five years (Queyrat, Lannelongue, Dennig). 
It is slightly more frequent among girls than boys. 

Pulmonary Tuberculosis. 

Seventy per cent, of the infants and children who die from tuber- 
culosis show lung-changes (Dennig). Infection first occurs through 
the respiratory tract. A cheesy lymph-node may burst into the 
bronchi J and bacilli may thus gain access to the lung alveoli and 
cause changes, as they do in the adult lung. Hsematogenous infec- 
tion occurs through the bursting of a small tuberculous nodule 
into a bloodvessel, thus flooding the lung with infectious matter, or 
by the carrying of minute emboli of this material to distant parts 
of the lung. 

Tuberculous bronchial lymph-nodes, bone, and pleura may also 
give rise to infection of the lung through the lymph-channels. 
The part played by the infectious diseases in its dissemination has 
been already mentioned. 

Morbid Anatomy. — The three principal forms of tuberculosis 
of the lungs which occur in infants and children are : 

The miliary form, which is characterized by the eruption of miliary 
tubercles throughout the lung. The lung is on section found to be 
dark red, hypersemic, and to contain less air than the normal lung. 
The bronchial mucous membrane is hypersemic and covered with 
blood and mucus. 

The cheesy or cheesy ulcerative form, also called florid phthisis, takes 
the form of cheesy lobar or lobular pneumonia. In recent cases the 
lung is grayish red, and there are areas which rapidly become cheesy, 
and are not encapsulated. These may coalesce, involving the greater 
part of a lobe in the process. Small cavities are frequent, large ones 
rare. The cheesy ulcerative form occurs as a result of the aspiration 
of large numbers of tubercle bacilli. 

The chronic form, which is a cheesy fibrous bronchopneumonia, is 
essentially a tuberculous bronchopneumonia. Round cheesy nodules 
are found surrounded by a fibrocellular zone resulting from the destruc- 



PULMONARY TUBERCULOSIS. 381 

tion of extensive areas of lung-tissue. The pulmonary pleura is 
thickened. The bloodvessels participate in the process. There is 
endarteritis with miliary tubercle in the walls of the bloodvessels, and 
there may be thrombosis. The tubercles may burst into the interior 
,of the bloodvessels. The bronchi, trachea, and larynx may be 
affected. There are ulcerations of the mucous membrane and 
destruction of cartilage. The bronchial lymph-nodes or glands are 
enlarged and infected in most cases of tuberculosis of the lungs in 
children. Henoch has, however, shown that the bronchial nodes 
may be tuberculous and greatly enlarged without involvement of the 
lung-tissues. Northrup found the bronchial lymph-nodes affected 
in 125 consecutive autopsies. The whole node is converted into a 
cheesy mass, which may soften and break down. If there is a 
perforation into a bronchus, masses of bacilli may be discharged 
into the lung. Perforation into the bloodvessels may also occur. 
The nodes may form small masses or large mediastinal tumors at 
the root of the lung. 

Localization. — The apices of the lungs of infants and children are 
not as in adults the region most frequently affected by tuberculosis. 
The first change may appear in the lower lobe or the lower portion 
of the upper lobe, and spread thence. This is accounted for by the 
miliary character of the affection in the lungs of infants and children 
(Rindfleisch), and also by the fact that in many cases the process 
spreads from the bronchial nodes or glands to adjacent parts 
(Weigert). 

The symptoms of tuberculosis of the lungs in infants and young 
children are not so characteristic as in the adult, nor is there a 
gradual development of the symptoms pointing to involvement of 
the lungs. After the fifth year of life the symptoms closely resem- 
ble those seen in the adult. As regards infants, we shall describe 
only clinical types of the disease. Even these exhibit many varie- 
ties. 

Henoch has described forms of tuberculosis in infants which 
closely resemble cases of marasmus due to gastro-enteric disease. 
In many of them there are steady emaciation and progressive 
muscular weakness ; the infant lies helpless ; the abdomen is re- 
tracted ; the eyes may present a conjunctivitis ; the cervical, axillary, 
and inguinal glands may be slightly enlarged ; there is constipation 
alternating with diarrhoea ; the skin is easily inflamed and abscesses 
may form. In the terminal period vomiting sets in. The lungs 
throughout the course of the disease may present few signs, or there 
may be evidences of a general bronchitis. In these slowly emaci- 
ating infants there is no cough of sufficient severity to indicate 
involvement of the lung. The terminal stage ma}^ present cerebral 
symptoms of a mild type, such as rigidity of the neck, with periods 
of stupidity alternating with irritability. The infants die with 



382 THE SPECIFIC INFECTIOUS DISEASES 

a progressive loss of flesh and strength. The temperature is for 
days normal or a little above normal. In other types the dis- 
ease is masked by an acute or subacute bronchopneumonia. In 
these cases the infant, after suffering from exposure or some infec- 
tious disease, suddenly exhibits all the signs of a bronchopneumonia. 
There are severe cough, high temperature, dyspnoea, and cyanosis, as 
in the ordinary bronchopneumonia. Death may ensue in a few days 
or in a week. In other forms fatal results take place after sev- 
eral weeks, with symptoms closely resembling those of a persistent 
bronchopneumonia of the ordinary non-tuberculous variety. In 
other cases the symptoms of an acute bronchopneumonia are present, 
sometimes complicated with empyema. Evacuation of the pus is 
followed by apparent improvement, and the empyema may even heal, 
but the infant or child gradually emaciates, and the cough, which may 
have abated, becomes aggravated. Examination of the chest reveals 
new areas of lung involvement. In these cases the pus does not 
always contain the tubercle bacilli. The empyema may be the result 
of mixed infection, and the pus may contain only simple streptococci, 
the physician being frequently misled as to the true condition. 
Many forms of tuberculosis of the lungs in infants and children 
cause death with the terminal symptoms of tuberculous meningitis. 
Especially characteristic in older children, as compared with the 
adult, are those cases of tuberculosis of the lung which follow some 
slight injury, blow, or exposure, and in which there are for weeks 
no signs in the lung or elsewhere to account for the gradual emacia- 
tion and intermittent or remittent temperature. After a variable 
length of time signs of involvement are detected at one apex, or 
posteriorly over the base or mid-area of the lung. Even then 
the cough may be absent and no sputum be expectorated. The 
child then has intervals of stupidity ; there is delirium at night 
accompanied by the typical hydrocephalic cry. Irritability of tem- 
per is marked, the emaciation is very rapid, and coma and death 
with terminal paralyses show that the infection has involved the 
cerebral meninges. 

The temperatuep: is irregular in course. It may be normal for 
a few days, after which it rises one or two degrees daily in the 
afternoon and falls to the normal toward morning. 

HEMOPTYSIS is very rare in infants. Henoch has seen 3 cases 
in young infants and 1 in a child of two years. Acker has reported 
a case in a child of three years. I have seen several cases in chil- 
dren of more than six years of age. 

Sputum. — Infants do not expectorate. At most a frothy mucus 
collects around the orifice of the mouth after a coughing spell. 
Even older children expectorate very little, and must be taught to 
do so. 

Course. — Up to the second year of life, the course of tuber- 



TUBERCULOSIS OF THE PERITONEUM. 383 

culosis of the lung is generally acute (Henoch). The disease may 
pursue a subacute course^ but it is rarely as prolonged as in the 
adult. In children above the fifth year its course closely resembles 
that taken in the adult. 

The diagnosis of tuberculosis of the lung in infancy and early 
childhood must, for the most part, be made from the history of the 
case. In many of the cases the physical signs in no way differ 
from those seen in non -tuberculous diseases. Cases in which 
marked consolidation of the lung persists, with progressive emacia- 
tion, and cases in which auscultation reveals the presence of cavities, 
are certainly suspicious. There is no reliable method of deter- 
mining the nature of an acutely developing bronchopneumonia ; 
the detection of the tubercle bacillus in the vomit, in the feces, or in 
the exudate of a complicating pleurisy or empyema^ is of diagnostic 
aid. 

The existence of enlarged lymph-nodes in the mediastinum or the 
root of the lung is, according to some authors, revealed by symp- 
toms of pressure. Pressure on the bronchi may give rise to dysp- 
noea ; on the large veins, to nervous congestion and cyanosis, or 
oedema of the lungs ; on the recurrent laryngeal nerves, to asthma 
or laryngospasm ; on the oesophagus to dysphagia. Although in 
exceptional cases such symptoms may be thus correctly interpreted, 
I believe with Henoch that diagnosis of these enlarged nodes during 
life is highly uncertain. 

Treatment. — From a study of the symptomatology it will be 
seen that the treatment of tuberculosis of the lung in young infants 
and children must be simply symptomatic. A case of suspected 
tuberculosis should be isolated from other children. The fever 
needs little attention if it remains low ; if high, it is treated as in a 
case of simple bronchopneumonia. The cough and restlessness are 
also treated symptomatically. 

Tuberculosis of the Peritoneum. 

{Tuberculous Peritonitis.) 

Occurrence. — According to the statistics of Dennig, Mliller, 
Biedert, and Simmonds, tuberculous peritonitis occurs in from 8 to 
21 per cent, of all the cases of tuberculous disease. Sixty-five per 
cent, of the cases operated on by Herzfeld were under the age of 
fifteen years. The frequency varies in difierent localities. 

Acute tuberculosis of the peritoneum is seen in acute phthisis 
as a complication, when there may be also an exudate with miliary 
tuberculosis of the peritoneum. This form of peritoneal tubercu- 
losis is of no clinical interest. 

Chronic Form. — This is the form under consideration. It is 



384 THE SPECIFIC INFECTIOUS DISEASES, 

rare in the newborn ; in a statistic of 100 cases Still found the 
disease most frequent from the second to the fifth year of life. 
Next in frequency was the period of five to ten years. 

Etiology. — Tuberculous peritonitis is rarely if ever primary, 
although such cases have been described by Henoch and Miiller. 
The peritoneum may become infected through the blood-channels 
(hsematogenous) ; under these conditions tuberculosis of the perito- 
neum is simply a feature of the manifestation of acute miliary 
tuberculosis. The peritoneum may become infected through the 
lymphatics or lymph -channels (lymphogenous). Under these con- 
ditions it is the result of infection from adjacent organs, such as the 
intestines, the genito-urinary tract, the mesenteric, peritoneal, 
retroperitoneal, or bronchial, lymph-nodes, and the vertebrae and 
pleura. 

Morbid Anatomy. — There are, according to Herzfeld, three 
main forms of tuberculous peritonitis : the miliary, submiliary or 
exudative form ; the nodular or sclerosing form ; and the adhesive 
form. 

The Miliary, Submiliary, and Exudative Form. — In this form there 
is an eruption on the peritoneal surface, of gray, transparent tubercles 
of varying sizes. The intestinal coils are covered with fibrin, and 
are slightly adherent to one another. There is a clear serous, sero- 
fibrinous, seropurulent, or even ichorous exudate (mixed infection). 

The Nodular or Sclerosing" Form. — In this form the quantity of 
the exudate in the abdominal cavity is small. The omentum is 
converted into a solid cylindrical mass, containing tumors of a tuber- 
culous nature as large as an apple. The mesentery is thickened and 
covered with tubercles. The intestinal wall is thickened and covered 
with gray or grayish-yellow tubercles, which may attain the size of 
tumors. The coils of gut are adherent, and the whole peritoneal 
cavity may be obliterated. 

The Adhesive Form. — In this form the intestines form an adherent 
mass, with masses of exudate between the coils of gut, forming 
pseudocysts. This exudate may be of a puriform nature. Aggre- 
gations of tubercles between the coils of gut break down and perfor- 
ate into the gut, or become adherent to the abdominal wall and 
perforate externally forming intestinal or abdominal fistulse. Per- 
foration may thus occur in the absence of any real ulceration on the 
mucous membrane of the gut. 

In addition to the above principal forms of tuberculous perito- 
nitis, mixed forms occur. 

The exudate in the peritoneal cavity may be purely serous 
(ascites), or the serum may, as in a case which I observed, have 
a chylous appearance, due to the admixture of fat. In other 
forms the exudate may be seropurulent, hemorrhagic, or, in mixed 
infections, putrid. In the purely ascitic variety the fluid is fr^e j in 



TUBERCULOSIS OF THE PERITONEUM. 



385 



the purulent form, it is frequently sacculated between the adhesions 
on the coils of gut. 

Symptoms. — The disease is, as a rule, insidious and slow in 
development. The stage of abdominal distention has usually been 
reached when the patient is first brought to the physician. The 
history shows that the child has been for some time gradually losing 
weight, that the appetite is capricious, and that there have been 
attacks of abdominal pain. This pain may be localized or radiate 
from one point, may be constant, or may resemble visceral neuralgia. 
Sometimes there is no history of pain, but it may be detected by 
pressure on parts of the abdomen. There may be a slight rise 
of temperature toward evening (Fig. 71) ; diarrhoea may alternate 
with constipation. The abdominal distention is the leading feature. It 
may take the form of a uniform ascitic accumulation (Fig. 72) ; the 
surface of the abdomen may be uneven and irregular (Fig. 73), and 
tumors with cystic formation may be felt through the abdominal 
walls. 

Fig. 71. 




Tuberculous peritonitis. Female child, five years of age. Ten days of her temperature 
immediately preceding operation (laparotomy). 

The movements, which are rich in fat, sometimes resemble icteric 
evacuations. This condition was formerly considered pathognomonic 
of tuberculous peritonitis (Biedert, Conitzer). 

Vomiting of fecal or biliary matter resembling that seen in 
appendicitis may occur. 

In marked contrast with these is a form which in its acute onset 
may simulate acute perforative peritonitis. In this variety the 
tubercle mass may cause perforation either of the appendix or the 
gut in its cavity. Symptoms of acute perforative peritonitis which 
in every way resemble those of appendicitis set in. It is only 
by resort to laparotomy that the nature of the affection can be 
discovered. 

Physical Signs. — The physical signs in the miliary and the 
nodular forms are due to the presence of free fluid in the abdominal 
cavity. If ascites is present, there will be the percussion-wave, the 
flatness in the flanks, and change of tympanitic area will occur with 
change in the position of the patient. If adhesions are present and 
there are encapsulations of fluid, the signs will not vary on chang- 
ing the position of the patient. On the other hand, in the adhesive 
25 



386 



THE SPECIFIC INFECTIOUS DISEASES. 



Fig. 72. 



form there will be evidences of tumor masses in the abdominal 
cavity, cystic formations caused by the encapsulated exudate, and 
little or no fluid. 

In cases of adhesions in tuberculous peritonitis of the miliary 
form, the fact that when the patient is in the recumbent position 

the coils of gut may here and there 
be seen outlined over the abdominal 
parietes, is of diagnostic value (Fig. 
73). I was able by this means to 
confirm the diagnosis of adhesions 
in one such case, and have detected 
them clinically in other cases in which 
this form of peritonitis had been diag- 
nosed. 

The liver may be enlarged as a 
result of amyloid degeneration or 
tuberculous interstitial hepatitis. 

The spleen may be enlarged as a 
result of amyloid degeneration. 

Rectal examination may reveal 
miliary nodules or peritoneal masses 
palpable through the walls of the 
rectum . 

The diagnosis is based on the 
slow and insidious onset, the colicky 
abdominal pains, abdominal tender- 
ness on palpation, the presence of 
ascites or tumor masses, constipation 
alternating with diarrhoea, progres- 
sive loss of strength, intermittent 
fever or slight rise of temperature in 
the evenings, and the presence of 
tuberculosis in other organs. At 
the outset tuberculous infection in 
other parts of the body may be difficult of detection. A rectal ex- 
amination should always be made. This form of peritonitis should 
be differentiated from the non-tuberculous form. Inasmuch as some 
authors, notably Unger and Nothnagel, doubt the occurrence of 
idiopathic non-tuberculous peritonitis, caution should be exercised in 
making a diagnosis of simple chronic peritonitis. Absence of ema- 
ciation and retrogression of symptoms by no means prove that the 
disease may not have been tuberculous, since some forms of tuber- 
culosis of the peritoneum present such peculiarities. 

This form of peritonitis must also be differentiated from cirrhosis 
of the liver, new growths, cardiac and renal affections. 

In some forms of tuberculous peritonitis, especially of the miliary 




Uniform abdominal distention due 
to ascites of tuberculous peritonitis ; 
enlarged spleen. 



TUBERCULOSIS OF THE PERITONEUM. 



387 



type, the child will fail to show a temperature above the normal 
for weeks, and, being in tolerably good condition, the question will 
arise as to the nature of the abdominal process. In these cases a 
diagnosis is facilitated by the use of tuberculin. A reaction may 
be thus attained varying from a degree or more above the normal. 



Fig. 73. 




Tuberculous peritonitis, miliary form, female child, five years of age. Irregular contour of 
abdominal parietes in the recumbent posture, showing intestinal agglutination. 



The patient is placed in bed, the temperature previously observed 
every three hours for a few days, and then is given subcutaneously 
0.25 milligramme of tuberculin. If no reaction takes place, 0.50 
milligramme is given after a few days. The dose may be increased 
to a milligramme with older children. A reaction takes place, if the 
process is tuberculous, within twenty-four hours ; though I have 
seen it delayed for forty-eight hours (Fig. 74). 

Course. — The course of the disease is chronic. Frequently the 



388 



THE SPECIFIC INFECTIOUS DISEASES. 



symptoms retrograde and there is an apparent recovery. The ascites 
may at times diminish, and again increase. The chronic forms 
unless operated upon lead to the formation of abdominal fistulse, to 
perforative peritonitis, to tuberculosis of the organs, and to amyloid 
degeneration of the liver and spleen, with emaciation, exhaustion, 
and death. 

Fig. 74. 




Tuberculin reaction. Miliary form of tuberculous peritonitis. Diagnosis confirmed by 
operation. Boy four years of age. 

Treatment. — Laparotomy, when advanced tuberculosis in other 
organs is not present, is, according to Herzfeld, curative in 54 
per cent, of cases. In a series of 29 cases of all ages operated upon 
by him, 19 were under the age of fifteen years. With operative 
treatment must also be combined the medicinal and hygienic treat- 
ment suitable to cases of pulmonary or local tuberculosis. On the 
other hand, in the forms which resemble cases of tabes meseraica, 
in which emaciation and cachexia are present before much exudate 
is formed, it is difficult to decide as to the propriety of operative 
measures, especially if diarrhoea be present. In these cases if the 
diagnosis is not certain, proper feeding should be begun and the con- 
dition of the patient improved before laparotomy is attempted. 



Other Forms of Tuberculosis. 

Tuberculosis of the larynx is rare in children. It occurs in 
from 3 to 4 per cent, of the total number of cases of tuberculosis 
(Reiner, Steffen, Barthez, Rilliet). Demme has reported a case in a 
child of four and one-half years. 

Tuberculosis of the Pleura and Pericardium. — Primary 
tuberculosis of the pleura is rare. Dennig reports that it occurred 
as a feature of general tuberculosis in 14 per cent, of his cases. 
Pericarditis of the tuberculous variety occurs in only 3 per cent, of 
the cases of general tuberculosis. 

Tuberculosis of the heart muscle is very uncommon. Sanger 



stomach and 
intestines. 


Mesenteric 
lymph-nodes. 


14 per cent. 

38 

31 

31 " 


21 per cent. 
57 " 
40 
53 



TUBERCULOUS MENINGITIS. 389 

reports a case in a child of nine months, and Demme one in a 
patient of five years. The endocardium may be involved in general 
tuberculosis (Perroud). 

Abdominal Tuberculosis. 

The following table shows the relative frequency of tuberculous 
involvement of the abdominal viscera : 

Peritoneum. 

Dennig ........ 8 per cent. 

Miiller 18 

Biedert 18 " 

Simmonds .21 " 



Tuberculous Meningitis. 

{Acute Internal Hydrocephalus ; Basilar Meningitis.) 

Occurrence. — Tuberculous meningitis has been observed in 
infants as early as the third month (Steifen). Barthez and Rilliet 
have seen cases in infants five months old. The frequency of tuber- 
culous meningitis varies with the locality. Dennig places the fre- 
quency of tuberculous meningitis among children who suifer from 
tuberculous disease at 60 per cent., while Medin found this form of 
meningitis in 15 per cent, of tuberculous children. It is most fre- 
quent in the nursing period ; 75 per cent, of all cases occur under 
the fifth year. The second year of infancy shows the greatest num- 
ber of cases (Steffen). It is more frequent among male than female 
children. 

Of 26 of my cases of tuberculous meningitis, substantiated either 
by autopsy or by the presence of tubercle bacilli in the fluid obtained 
by lumbar puncture, 46 per cent. (12) were under four years of age, 
53 per cent, were four years of age or over ; the average age was 
four years and four months. The oldest case was ten years, and the 
youngest seven months. 

Etiology and Morbid Anatomy. — Exposure to cold and trau- 
matism predispose to the affection. In many cases there is, in addition 
to the meningeal disease, disseminated tuberculosis of the Inngs, 
pleura, spleen, liver, and peritoneum. In other cases the meninges are 
the chief seat of the disease, only a few isolated foci of tuberculosis 
being present elsewhere, as in the mesenteric or bronchial lymph- 
nodes. It is rare to find the lesions confined to the meninges, 
and some authors deny the possibility of such a condition. It is 
not always possible to determine the primary focus of infection. 

The tubercle bacilli, which are the causative factors, may be 
carried by the blood (hsematogen) to the meninges, and there give 
rise to a more or less extensive miliary deposit. The original focus 



390 THE SPECIFIC INFECTIOUS DISEASES. 

in such cases may have been a cheesy lymph-node, a tuberculous 
nodule in the lung, or a carious bone or joint. The tubercle bacilli 
may enter the lymph-channels from an adjacent carious bone of the 
skull, a diseased mastoid, or a spinal vertebra. An ozsena or a soli- 
tary tubercle of the brain may give rise to tuberculous meningitis by 
this mode of transmission. Whatever the focus, at the point of in- 
fection there will result an eruption of tubercles which may remain 
localized or become disseminated along the course of the cerebral 
lymph-channels. When the dissemination of bacilli occurs through 
the blood, miliary tubercles are found in the course of the bloodves- 
sels and in their walls. The tubercles may remain confined to the 
meninges or may involve the brain-tissue, constituting a meningo- 
encephalitis. In the meshes of the meninges (pia) there is a sero- 
fibrinous or seropurulent exudate, which is also found in the ventricles 
(hydrocephalus), and which infiltrates the brain-tissue itself (men- 
ingo-encephalitis). If the exudate is limited in quantity and the 
tuberculous process is localized, forming one, two, or three nodules, we 
speak of tuberculosis of the brain or solitary tubercles of the brain. 
The tubercles are seen as grayish shining nodules surrounded by a 
hypersemic zone. They vary from microscopic size to large yellow 
nodules, which are of older origin. They may be strung along the 
vessels or break through their walls, forming thrombi with subse- 
quent hemorrhagic infarction. 

The basal branches of the artery of the Sylvian fissure are usually 
the seat of the eruption of these tubercles. The tuberculous process 
is generally bilateral, but one side, usually the left, may alone be 
the seat of disease. Tuberculous meningitis aifects by selection 
the base of the brain — hence the term basilar meningitis. The 
convexity may be involved in the process, although it is rarely 
the seat of tuberculous meningitis unless the base of the brain is 
affected. Steffen and Henoch have described cases of isolated 
tuberculous meningitis of the convexity of one or both sides. The 
base, the vicinity of the pons, and the chiasm are the seats of the 
process. In all forms, the pia is infiltrated with serofibrinous or 
seropurulent exudate. The choroid plexus may be involved. Acute 
hydrocephalus then results. 

The brain-tissue itself is the seat of inflammatory infiltration, 
and the nerves at the base are surrounded with exudate and are in 
process of degeneration. The ependyma of the ventricles (the 
lateral, third and fourth) are the seat of inflammatory thickening and 
eruption of tubercles. These cavities are filled with exudate. The 
meninges of the spinal cord, the cord itself, and the nerves at the 
points of exit are frequently involved in the tuberculous meningitis, 
as has been demonstrated by Leyden, Erb, and Dennig. The latter 
found the cord involved in 9 out of 10 cases. The pia may be in- 
volved to a slight degree. The nerves at the points of exit are 




> 
X 



TUBERCULOUS MENINGITIS. 391 

involved in inflammatory exudate. The tissue of the cord and the 
nerve-elements may be the seat of degenerative processes. 

The symptoms of tuberculous meningitis cannot be clearly clas- 
sified according to stages. There is an indefinite period of premoni- 
tory symptoms followed rather abruptly by manifestations of cerebral 
irritation, and ending with a period in which pressure-symptoms are 
pronounced. As a rule, the disease is slow of development, although 
cases occur in which the rapid malignant course simulates that seen 
in rapidly fatal cerebrospinal meningitis of the epidemic type. The 
disease gives a varying clinical picture in the different periods of 
childhood. The infant of from seven to twelve months refuses to 
nurse, has a low fever, and may have diarrhoea alternating with 
obstinate constipation. The illness of an infant is often attributed 
to a fall occurring while it was learning to walk. A weakness 
of the extremities is thus indicated. The infant becomes indifferent 
to its surroundings and passes into a somnolent condition. Emacia- 
tion is progressive. Vomiting occurs once or twice daily, the food 
being ejected from the mouth after nursing without apparent effort. 
The vomiting may be followed by a convulsion, after which the 
infant becomes unconscious. There may be strabismus, or rigidity 
of the extremities, or the extremities may be in constant motion of an 
automatic character. The convulsions may follow one another with- 
out cessation. These symptoms may set in after a period of one, two, 
or five weeks of ailing. In other cases the infant may have suffered 
from a chronic otorrhoea, although otherwise in apparent health. 
Suddenly, vomiting followed by a convulsion sets in. This convul- 
sion is the forerunner of symptoms, such as coma, which denote that 
the disease has become established without having attracted the 
notice of the parents. In children of five years of age the symptoms 
are more marked. The child may have an attack of vomiting and 
diarrhoea and apparently recover ; after a few weeks, during which 
there are irritability, loss of appetite, and progressive emaciation, the 
child no longer desires to be up and about, but lies quiet in its crib, 
with its head in a characteristic rigid position. It develops strabismus, 
becomes soporose, and cries out at night. This cry is sometimes pierc- 
ing in character, and is the cause of much concern to the mother. When 
the symptoms of cerebral pressure are fully developed, the picture is 
in the majority of cases much the same. The infant after the first con- 
vulsion lies in a soporose or comatose condition. The eyes are open 
and there is a vacant stare ; the sclera may be apparent above the 
cornea ; the fontanelle if still open is tense and bulging, and there 
may be horizontal nystagmus. The infant cries if disturbed, or may 
be indifferent to its surroundings. The pupils may be unequal in size 
and react to light. In one case which I observed the pressure- 
symptoms were extreme. The infant lay on its back with rigid neck 
and arched back (opisthotonos), and emitted a piercing cry at in- 



39^ THE SPECIFIC INFECTIOUS DISEASES. 

tervals. At each cry the pupils became successively dilated and 
contracted (hippus). I have seen this phenomenon in two cases 
of tuberculous meningitis. Opisthotonos may be present, and the 
retraction of the head may relax at intervals, the muscles of the 
back being lax. In some cases there is apparently no rigidity of the 
neck. As a rule there are no convulsions. As the infant or child 
lies quietly in its crib the inspirations during the stage of cerebral 
pressure may be very irregular or may be of the Cheyne-Stokes 
type. The outline of the abdomen is at first normal or there may 
be a slight retraction at the upper part. The abdominal wall 
may be quite lax, so that the coils of gut can be made out. If 

Fig. 75. 





Babinski's reflex. Tuberculous meningitis ; stage of facial palsies. Boy, seven years of age. 

the case is protracted, retraction of the abdomen occurs in the 
final stages of the disease. This condition has been described 
as the boat-like abdomen. It is not diagnostic of this form of 
meningitis. 

In rare cases spastic symptoms closely resembling those of tetany 
occur after the initial convulsion. The infant lies comatose, with 
rigidly flexed arms ; the Chvostek and Trousseau symptoms are 
present. In all of these cases, if the skin is stroked with the finger 
ever so lightly, a red mark appears over the stroked area (tache cere- 
brale). In the spastic cases the knee-reflexes may be increased, but 
in the non-spastic cases they are diminished. It is difficult to elicit 
Kernig's symptom in spastic cases, because the infants lie with the 



TVBEkCULOVS MENINGITIS. 



393 



knees flexed. By straighten- 
ing the legs and thighs it is 
possible in the majority of 
children to obtain the symp- 
tom. 

The most important symp- 
toms of the final stage of 
tuberculous meningitis, both 
in infants and older children, 
are the localized facial palsies. 
For several days or weeks 
preceding the fatal issue, one 
side of the face is seen to be 
flatter than the other. There 
may be ptosis or lagophthal- 
mus of the eyelids. One eye 
may be rotated internally, 
owing to paralysis of the 
abducens. The extremities 
are also paretic. The arm 
and leg of one side may be 
rigid or flexed, while those 
of the opposite side are lax. 
Irritation of the soles of the 
feet may give a Babinski re- 
action (Fig. 75). In some 
cases this reaction is present 
independently of any irrita- 
tion of the plantar surface. 
Toward the end, convulsive 
twitchings appear in the 
muscles of one or the other 
side of the face or of the ex- 
tremities. Death supervenes 
in coma with convulsions. 
The heart may continue to 
beat for some time after the 
cessation of respiration. 

Children from six to nine 
years of age present a more 
decided clinical picture in 
the premonitory stage. For 
some weeks before the onset 
of symptoms of irritation 
they complain of headaches, 
frontal, sincipital, or parietal. 





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394 



THE SPECIFIC INFECTIOUS DISEASES. 



The patient is listless, walks with an unsteady gait, and has no 
desire to study or play. A discharge from the ear may have 
been present for months before the onset of these symptoms. In 
one case the child had for some time complained of pain in the 
left side of the chest and had lost weight steadily. There were 
mild pleurisy and signs of slight consolidation at the apex of 
the left lung. There was daily elevation of a few degrees of tem- 
perature in the evening, and a normal temperature in the morning. 
In this case, although there were distinct signs of pulmonary 
involvement of a mild type, the emaciation was progressive and 
the leucocyte counts low (8000 W.B.C.). At night the typical 
cry of tuberculous meningitis was present. In the early stages 
of the disease the patient was conscious during the day, but later 
became listless, irritable, and slept or was drowsy during the day. 



Fig. 77. 



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Tuberculous meningitis, observed from the outset of the symptoms. Female infant, fourteen 

months old. 

When questioned, a slow stupid answer was given. The child vomited 
and at times became nauseated. The Kernig symptom appeared. 
Right lagophthalmos was present. The pupils were unequal in size, 
the left being dilated. The pulse at this time varied from 60 to 
100 and was compressible. Finally, coma set in with left facial 
palsy and convulsive twitchings of the left side of the face. This 
case was for three months under constant observation. In other 
cases the vomiting is rapidly followed by paralytic symptoms such 
as ptosis and facial paralysis on the same side. There are no convul- 
sions and no cry, but there is rigidity of the neck and extremities ; 
one patellar reflex may be absent. The Kernig symptom and 
Babinski reflex are present in the majority of cases in children. 



TVBEBOilLOUS MENINGITIS. 



395 



The very rapid and fatal cases of tuberculous meningitis have 
been described by Osier and Dennig. In these the patient is over- 
whelmed by the toxaemia of the disease, no marked tuberculous 
lesion being present in any organ but the brain. A patient in 
apparently good health is suddenly seized with convulsions followed 
by a period of unconsciousness. There are muscular relaxation and 
a vacant stare. The convulsions may be repeated at intervals of a 
few minutes or half an hour. There then follow opisthotonos and 
spasms, and the abdomen is tympanitic. There is neither vomiting, 
tache, nor elevation of temperature. There are spastic contractures of 
the extremities alternating with relaxations. Death occurs in a con- 
vulsive seizure within ten hours. 

Schlessinger reports a case of tuberculous meningitis in a child 
two and a half years old, setting in with convulsions, followed by 
hemiplegia and aphasia within thirty-six hours. After these pre- 
monitory phenomena the ordinary symptoms of the disease appeared. 
Such cases are exceedingly rare. 

The temperature-curve in tuberculous meningitis is not charac- 
teristic. In some cases the temperature will not rise more than a 

Fig. 78. 



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Tuberculous meningitis ; general miliary tuberculosis ; terminal stage ; coma and paralysis. 

Boy, seven years of age. 



degree or two above the normal, intermitting to the normal or nearly 
so. In other cases it may be normal for days, then rise a degree or 
more, rarely above 103° F. (39.4° C), and then fall again to the 
normal. In cases in which there is a general miliary process the 



396 THE SPECIFIC INFECTIOUS DISEASES. 

temperature mounts to 105°-106° F. (40.5°-41.1° C.) or higher 
toward the close. The fatal issue in other cases occurs with a sub- 
normal temperature (96° F., 35.5° C.) lasting for a day or more be- 
fore death. If the case is a protracted one, the normal diurnal varia- 
tions may be reversed — that is to say, the highest temperature may 
be reached in the morning hours and the lowest toward evening. 
In the majority of cases, however, the temperature is rarely higher 
than 103° F. "^(30.4° C). 

The pulse is increased at the onset, but during the course of the 
disease becomes slow and may range from 60 to 100 or more during 
the twenty-four hours. 

The respirations are irregular, and may vary from 18 to 60 with- 
in the twenty-four hours, even if no pulmonary lesion is present. 

Individual Symptoms. 

Onset. — Of 26 cases which I have utilized for the purposes of 
this article, the onset was slow and insidious in 77 per cent. The 
mother of the child related that the patient was not quite well, or 
complained of slight headache, and vomited from time to time 
before the appearance of marked symptoms. In those cases which 
have come under my observation early in the disease, as early as 
the second day after marked symptoms were observed by the 
parents, there was no history of vomiting ; as a rule, the child 
had a slight elevation of temperature, was irritable from time 
to time, refused to nurse, and on the whole the mother observed a 
change in the general attitude of the child toward herself and others. 
It was only in those cases which had lasted at least a week that there 
was a history of vomiting. It was in exceptional cases, as in one 
case two years ago, in which the mother asserted that the disease 
began suddenly with vomiting and convulsions. 

Vomiting. — Vomiting sets in, on the average, eighteen days before 
the fatal issue, and may occur once or twice daily. It may be 
absent in some cases. With the vomiting there may be localized 
convulsions, which appear with the vomiting, as has been stated 
in exceptional cases in which the onset was sudden, or may appear 
two weeks after the initial vomiting attack. 

Rigidity. — There are some cases of tuberculous meningitis in 
which rigidity of the neck is absent throughout the disease. In 
only one of my cases was there opisthotonos ; and the rigidity, if 
present, as a rule, was but slightly marked ; that is, the head was 
movable almost to a normal degree. The rigidity is tested simply 
as the child lies in bed y the head is raised, or an attempt made 
to draw the chin toward the sternum and note the resistance. In 
only 25 per cent, of the cases was there palpable rigidity or stiff- 
ness of the neck, and this appeared late in the course of the disease. 



INDIVIDUAL SYMPTOMS, 397 

Hypersesthesia. — Hypersesthesia, either of the surface or of the 
senses, is absent, as a rule, in tuberculous meningitis ; that is, the 
child reacts feebly or not at all to irritation, and would, when 
roused, momentarily protest and then fall into sopor again. In 90^ 
per cent, of the cases there was an absence of hypersesthesia either of 
the surface or of the senses ; and in this respect tuberculous menin- 
gitis is quite the opposite of cerebrospinal forms of meningitis of 
the epidemic type, in which hypersesthesia is the rule and forms part 
of the general symptomatology of the disease. 

Kernig Symptom. — This symptom is present in only 50 per cent, 
of the cases. It was absent in the others. Its presence or absence 
does not materially aid in the diagnosis. 

Babinski Reflex. — In children over two years of age the Babinski 
reflex is a valuable guide clinically as to the nature of a meningitis, 
if meningeal symptoms are present ; more so than the Kernig 
symptom. 

Of 26 cases of tuberculous meningitis, the Babinski reflex was 
present in 15. It is found exceptionally in the cerebrospinal men- 
ingitis of the epidemic type, or the suppurative forms of meningitis. 

The general reflexes are present in tuberculous meningitis early 
in the disease ; whereas late in the disease, when paralysis super- 
venes, they are absent. 

Pulse. — The irregularity of the pulse is of no special diagnostic 
value in tuberculous meningitis, and if present is only incidental. 
The irregularity of the pulse is quite a feature in other forms of 
meningitis, especially the cerebrospinal type. In these cases the 
pulse at one moment may be 85, and immediately after may suddenly 
mount to 120 beats a minute. In tuberculous meningitis, however, 
the pulse, as a rule, is slower than that of meningitis of the cerebro- 
spinal type. 

Respiration. — The respiration is irregular in most forms of me- 
ningeal trouble in children. In the tuberculous form of meningitis, 
after the disease is well inaugurated, the respirations are irregular 
and shallow, and in a few cases, where cerebral pressure is very 
marked late in the disease, the respirations may assume the so-called 
Cheyne-Stokes rhythm. The irregularity of respiration or pulse is 
scarcely an aid as to differential diagnosis of the form of meningitis 
present. 

Temperature. ^Of greater utility in the diagnosis is an exact 
observation of the course of the temperature. Although there are 
cases of tuberculous meningitis in which the temperature ranges as 
high as 104° to 105° F., this high temperature is present only in 
the presence of complications of the lung, or at a late period of the 
disease, toward the fatal issue. In most cases of tuberculous men- 
ingitis which I have seen, a low range of temperature has been the 
rule. 



398 THE SPECIFIC INFECTIOUS DISEASES. 

Blood. — In all my cases of tuberculous meningitis I have had the 
blood examined at intervals of three days ; in two-thirds of the cases 
there was a leucocyte count ranging below 20,000 to the cubic 
millimetre. In the remainder of the cases, however, I obtained a 
leucocyte count ranging from 20,000 to 25,000 to the cubic milli- 
metre. In some cases there was at some period of the disease a 
so-called leucopenia. In no case except one, in which the leuco- 
cytes just before the fatal issue mounted to 32,000 to the cubic 
millimetre, did the leucocyte count exceed 25,000 to the cubic 
millimetre ; therefore a leucopenia, however presumptive evidence 
in the face of other symptoms of the tuberculous form of menin- 
gitis, is certainly not a positive evidence of the presence of the 
disease. The lowest count in my cases was 5000 leucocytes to the 
cubic millimetre. 

Eyes. — The condition of the fundus of the eyes is of special 
interest in this form of meningitis, as compared with the condition of 
the disk and retina in other types, such as the cerebrospinal form of 
meningitis. In 20 consecutive cases of tuberculous meningitis 
examined by the expert ophthalmologist in my hospital service, the 
fundus was normal at an early or late period of the disease in 25 
per cent, of the cases. In 75 per cent, of the cases, however, there 
was some change in the disk (optic neuritis), or there were present 
also tubercles in the choroid. In some cases the disk was simply 
swollen, and indistinct at the margin ; in other cases the veins were 
congested. Tubercle was found in the choroid in 6 of the 20 cases 
examined. Choroid tubercle was seen as early as the first and as 
late as the sixth week of the disease. 

The cerebral cry present at night is not distinctive of this form 
of meningitis ; the emaciation, the retraction of the abdomen, the 
bulging of {he fontanelle may be present in other forms of meningitis, 
especially in that form described by English authors as the postero- 
basic form. Of great service in making a clinical diagnosis in this 
disease is the presence of palsies of the cranial nerves, facial paral- 
ysis ; ptosis, strabismus, paralysis of the internal rectus of one side, 
or ptosis of one side with or without lagophthalmos of the opposite 
side, are indicative of a lesion at the base of the brain. These 
palsies are seen more frequently in the tuberculous forms of menin- 
gitis than in the epidemic cerebrospinal type of meningitis. I 
have, however, seen these palsies in cases of cerebrospinal menin- 
gitis either in infants or children, and in these cases the palsies 
appeared early in the disease rather than late, as in the tuberculous 
form. 

Macewen's Sign. — This sign is elicited by percussion along the 
parietal or frontal bone over the situation of the anterior horn of the 
ventricles, and in infants and children below two years of age is of 
very little value as to the diagnosis of tuberculous meningitis with 



INDIVIDUAL SYMPTOMS. 399 

consequent accumulation of fluid in the ventricle as a result of this 
disease, inasmuch as in certain children suffering from pronounced 
rachitis with slight accumulation of fluid in the ventricles, so-called 
hydrocephalus, this tympanitic note of Macewen may be obtained. 
The Macewen tympanitic note is therefore of value only in children 
above two years of age, and must always be sought by sitting the 
patient upright in bed, inclining the head toward one or the other 
shoulder, and percussing the inferior side of the skull over the 
parietal or frontal bone. When carried out in this manner, a marked 
tympanitic note over the anterior horn of the ventricle is presump- 
tive evidence of fluid in the same as a result of inflammatory 
processes at the base of the brain and obstruction of the veins of 
Galen. 

Lumbar Puncture. — Lumbar puncture is to-day the most valuable 
aid we possess in making a positive diagnosis of the various forms 
of meningitis. In tuberculous meningitis there has been discussion 
as to the value of an examination of the puncture fluid in the 
diagnosis. First, as to the cyto diagnosis, it may be said that in 15 
of my cases of tuberculous meningitis studied with a view of 
noting the character of the cell elements in the puncture fluid, 14 
showed a predominance of mononuclear cells. In 1 case there was 
an equal number of mononuclear and polynuclear cells. It would 
seem, therefore, that in tuberculous meningitis there is a prevalence 
of mononuclear cells, and that this is so constant that it would 
appear to be characteristic. There are forms of cerebrospinal 
meningitis, however, especially the chronic cases, and those of the 
posterior-basic type of long duration, in which, instead of a poly- 
nuclear picture in the sediment of the fluid obtained by lumbar 
puncture, the mononuclear picture is apt to present itself, thus closely 
resembling what is seen in tuberculous meningitis. 

The bacteriology of the fluid obtained from cases of tubercu- 
lous meningitis by means of lumbar puncture has been a matter 
of close study and difference of opinion ; whereas Lichtheim, Len- 
hartz, and Bernheim found that tubercle bacilli were constant in the 
sediment of the fluid obtained from these cases ; Cassell and 
Marfan have asserted that their presence is only occasional. Of 
late we have examined the puncture fluid of 14 consecutive cases 
of tuberculous meningitis, which were clinically diagnosed as tuber- 
culous in character before the puncture. In 13 of these cases 
tubercle bacilli were found. The fluids were carefully centrifuged, 
and the search in some cases was exceedingly painstaking. In 
some cases, especially of children coming under observation late in 
the disease, tubercle bacilli were not found during life in the puncture 
fluid, but were found post mortem. This is explained by the fact 
that in these cases the tubercle bacilli were present in but few num- 
bers which during life were kept evenly distributed throughout the 



400 THE SPECIFIC INFECTIOUS DISEASES. 

subarachnoid space, and were found in the puncture fluid only after 
prolonged search. I am inclined to believe that the search for 
tubercle bacilli in the puncture fluid obtained from cases of tubercu- 
lous meningitis is the most positive and valuable aid to the diag- 
nosis, and the bacilli can be found in the majority of cases, if 
carefully looked for. 

Differential Diagnosis. — Tuberculous meningitis must be differ- 
entiated from epidemic cerebrospinal meningitis or sporadic cerebro- 
spinal meningitis, suppurative forms of meningitis, posterior-basic 
meningitis, apex pneumonia, typhoid fever, sepsis, disturbances of 
the stomach and gut, uraemia, helminthiasis, and finally the various 
forms of otitis. From cerebrospinal meningitis it can be diff*er- 
entiated by the slow onset, by the absence of opisthotonos, and in 
the majority of cases a slight rigidity of the neck, by the absence 
of hyperaesthesia, the presence of changes in the fundus of the eye, 
either optic neuritis or the presence of choroid tubercle, which will 
be absent in cases of cerebrospinal meningitis and posterior-basic 
meningitis, by the low range of the temperature, by the absence 
of a leucocytosis above 25,000 to the cubic millimetre, and finally 
by the results of an examination of the fluid obtained by lumbar 
puncture. 

Pneumonia with cerebral symptoms may simulate tuberculous 
meningitis. Here again the history and the character of the delirium 
in older patients will aid us. The signs in the lung and the pres- 
ence of leucocytosis, which is marked in pneumonia and generally 
absent in tuberculous disease, are significant. In the majority of 
cases of typhoid fever the history will be of service in connection 
with the roseola, the Widal reaction, the enlarged spleen, and the 
absence of leucocytosis. Diarrhoea may be present in typhoid. 

Disturbances of the gut, uraemia, and helminthiasis may present 
symptoms resembling those of tuberculous meningitis, but the symp- 
toms in time retrograde or are cleared up by a study of the case. 

I have seen otitis media in nurslings with very limited areas of 
bronchopneumonia, simulate tuberculous meningitis. In these cases 
the infants may have been ill for two weeks or more. They start 
from sleep, are irritable on awakening, and lose appetite. 

In one case the ocular symptoms closely simulated those of tuber- 
culous meningitis. As a rule there are intervals during which the 
child is not only free from pain, but also has a normal temperature. 
At other times the temperature has a septic intermittent character, 
and mounts higher (104° F., 40° C.) than in tuberculous meningitis. 
Aural examination only will remove doubt. 

The duration of the disease varies within wide limits ; I have 
seen cases which extended over three months. The majority of 
cases last from two to three weeks, but cases lasting five weeks are 



SYPHILIS. 401 

not unusual. The very rapid cases in which death ensued within 
twenty -four hours have been mentioned. 

The prognosis is always fatal. Isolated cases of recovery have 
been reported, but should be regarded with doubt. 

The treatment is directed to alleviating the sufferings of the 
patient. Lumbar puncture is not curative, and should not be 
repeated after the first diagnostic puncture has been performed. 

Tuberculosis of the Brain. 

[Solitary Tubercle of the Brain.) 

In this there may be a single localized tuberculous nodule or 
mass in the brain, or several such formations may be present. 
Demme found a growth of this kind in an infant twenty -three days 
old. Henoch has published a case in an infant eleven days old. The 
majority of cases occur between the second and the fifth year. 

Morbid Anatomy. — Tubercle bacilli of diminished virulence 
and limited number are carried from the focus of tuberculosis to the 
brain through the blood-channels, and there lodged in a terminal 
bloodvessel, forming solitary tuberculous masses varying from the 
size of a pea to that of a hazelnut. These are surrounded by a 
zone of granulation-tissue. The neuroglia in the immediate vicinity 
is the seat of proliferation, and may form a capsule around the 
growth. Circumscribed meningitis over the situation of the growth, 
with adhesions of the pia mater to the dura, may be present. Fully 
half of these solitary growths occur in the cerebellum (Gerhardt). 
The growth may be single or there may be one large growth and 
several of smaller size. Starr and Seidl found a solitary growth in 
77 per cent, of the cases. The larger number of brain tumors in 
infancy and children are tuberculous. Starr found this variety in 
152 out of 300 cases of all kinds of tumors. 

The symptoms are those common to all tumors, and will be de- 
scribed in the section devoted to Brain Tumors. 

XVIII. SYPHILIS. 

Acquired Syphilis of Infancy and Childhood. 

Etiology. — Of 42 cases of acquired syphilis collected by Four- 
nier, 19 were infected by the father or mother after birth, and 8 
by the nurse. No case was infected in passing through the ma- 
ternal parts, and no infant was infected by the mother if she had 
contracted the disease just prior to her accouchement. A child of 
a syphilitic mother, if born free from signs of syphilis, cannot con- 
tract a primary lesion at birth from the maternal parts, even if 
these parts are the seat of condylomata, nor can such an infant be 
86 



402 THE SPECIFIC INFECTIOUS DISEASES. 

infected subsequent to birth. It has an acquired immunity against 
the disease. 

A chancre or primary lesion is, in the infant as in the adult, the 
only evidence of acquired syphilis. It is the result of infection, and 
must be present in order that the diagnosis may be certain. Chan- 
cres are rarely genital. They are found, as a rule, in the mouth, on 
the face, and on the abdomen and perineum. An infant may be in- 
fected by the nipple of the nurse's breast. The act of kissing, con- 
taminated nipples of the nursing-bottle, instruments, sponges, ritual 
circumcision, and humanized vaccine virus, are all means of infect- 
ing the infant. Since humanized vaccine virus is no longer used, 
this mode of infection has been eliminated. 

The symptoms consist of a chancre or initial lesion, rarely gen- 
ital, which appears three or four weeks after inoculation. The other 
accidents, such as bubo or adenopathies, the eruption, and all the 
secondary symptoms of acquired syphilis, appear in due course as in 
the adult. The genital chancre is seen in infections caused by ritual 
circumcision. 

The prognosis as to life is good in comparison with that in the 
hereditary form of the disease. While in the hereditary form the 
mortality is from 70 to 80 per cent., that in the acquired form is 
very low. Fournier lost only 1 in 42 cases of acquired syphilis. 
The course in infants and children is benign. The chancre is not 
well developed ; the induration is present only a short time, or may 
even escape notice. The infants enjoy good health in spite of the 
presence of the secondary symptoms. I have confirmed these state- 
ments by observing 7 cases of genital chancre. The tertiary mani- 
festations, such as gummata, bone lesions, joint-aifections, eye and 
laryngeal symptoms, and cerebrospinal lesions, appear from five to 
twenty-five years after the initial lesion. 

Differential Diagnosis. — Acquired syphilis must be differenti- 
ated from the hereditary form of the disease. Hereditary or con- 
genital syphilis appears early without an initial lesion, showing gen- 
eral secondary symptoms from four to six weeks after birth. The 
chancre is the first manifestation in acquired syphilis. In Fournier's 
42 cases the chancre appeared during the first year of life in 19, and 
during the second year in 10 cases. The snuffles, pemphigus, and 
pseudoparalysis are not present in acquired syphilis. Secondary 
accidents, such as mucous patches or papules about the genitals, 
appearing during later childhood are probably traceable to a post- 
natal infection. Interstitial keratitis, bone syphilis, and cutaneous 
stigmata are common to the hereditary and acquired forms of the 
disease. It is sometimes very difficult to decide which form of the 
disease is present. Thus far no one has shown conclusively that 
Hutchinson's teeth are present in acquired forms of syphilis in 
infancy and childhood. Their presence is therefore strong presump- 
tive evidence of hereditary syphilis. 



LATE HEREDITARY SYPHILIS. 403 

Late Hereditary Syphilis. 

{Syphilis Hereditaria Tarda.) 

Fournier defines late hereditary syphilis as a symptom-complex 
of accidents of syphilis originating in a hereditary infection, which 
manifests itself at a more or less advanced period of life, that is 
to say, in the majority of cases between the third and the twenty- 
eighth year. There are two classes of cases. In the first, the 
patient has remained in perfect health without any of the eruptive 
or other symptoms of hereditary syphilis until at an advanced period 
of childhood one or more of the symptoms of late hereditary syphilis 
are developed. In the second, the late symptoms have been pre- 
ceded by the early symjitoms of hereditary syphilis. The late symp- 
toms may develop after an interval of from ten to fifteen years. The 
cases of the former class have been the subject of much discussion. 
The occurrence of the second class of cases is now well established ; 
it is often very difficult to determine the hereditary or acquired 
nature of the original infection. 

Fournier, in classifying the symptoms of 212 cases of late heredi- 
tary syphilis, found the eye to be the organ most frequently aifected. 
Next in order of frequency are the lesions of the bones and skin. 
The rarer affections are those of the kidney, larynx, spinal cord, 
testes, and lungs. 

The subjects of late hereditary syphilis have certain well-defined 
general characteristics. They are constitutionally delicate and have 
an emaciated habitus. The skin presents a grayish anaemia. There 
is an arrest in the development of bone and musculature. The men 
are undersized and present the picture which has been characterized 
as infantilism. The signs of virility, such as the beard, hair under 
the arm and on the pubes, are scantily developed. The testes are 
rudimentary. The adult has the appearance of a boy of fourteen or 
fifteen years. The women are correspondingly backward in develop- 
ment. 

The Eye. — The eye symptoms appear most frequently at the age 
of ten or fifteen years, but may become evident as early as the third 
year. The principal symptom is a keratitis of the diffuse intersti- 
tial variety, the so-called keratitis of Hutchinson. The cornea has 
a slightly cloudy or filmy appearance, or the whole structure is dif- 
fusely opaque. The other ocular accidents are plastic iritis, which 
fixes the iris, thus limiting its action and causing a difference in the 
size of the pupils. The rarest manifestations are miliary gummata 
of the iris. 

The bone-lesions are most frequent between the fifth and the 
twelfth year. 

The head presents a cuboidal shape ; the forehead is prominent ; 



404 



THE SPECIFIC INFECTIOUS DISEASES. 



the frontal bones have large bosses, as have also the parietal bones. 
The longitudinal suture is depressed, giving a natiform shape to the 
head. The cranium may have the form seen in mild degrees of 
hydrocephalus. 

The nose, on account of the destruction of the bony septum, has 
a depressed bridge. The bony and cartilaginous septa form an acute 



Fig 




Late hereditary syphilis ; bone deformity and sinus. Child, three years of age. 

angle, and a peculiar retrousse appearance is given to the organ. 
Both bony and cartilaginous septa may be destroyed. The whole 
organ is flattened, the tip of the nose being wrinkled into three or 
more folds. 

The long hones are especially affected by the accidents of late 
hereditary syphilis, the tibia being most frequently affected. The 
lesion may consist in an osteoperiostitis, a gummatous osteoperiostitis, 
or a gummatous osteomyelitis. 

If osteoperiostitis is present, there are diffuse swelling and thicken- 
ing of the bone — the so-called sabre-like deformity (Fig. 79.) This 
process may affect the long bones of the upper extremities. The gum- 
matous lesions of osteoperiostitis form numerous irregular painful 
swellings on the bone. Gummata are present on the flat bones of the 
cranium. When these break down, the destructive processes may 
expose the dura mater. Arthropathies with synovitis may be mis- 
taken for tuberculosis of the joint. This form of synovitis is gen- 



CONGENITAL OR HEREDITARY SYPHILIS. 405 

erally bilateral. One of my cases, a child five years of age, gave 
no history of syphilis. The radius on both sides was affected by 
osteoperiostitis. The joints may be deformed by osteophytic growths 
involving the epiphysis or head of the bone. 

The ear is affected by an otitis with destruction of the ossicles, 
and even by mastoid disease. In other cases deafness supervenes 
without premonitory symptoms. 

The skin and mucous membranes show certain stigmata in the form 
of cicatrices of recent or old ulcerations. These may exist on any 
part of the body, but are especially characteristic on the vermilion 
border of the lips and at the corners of the mouth, where they are 
seen as radiating, linear pale-white fissures. 

The lymph-nodes may be enlarged, especially those on each side 
of the neck, below the jaw, and in the axilla and inguinal regions. 

The spleen is enlarged, but not so frequently as is stated by some 
authors. Fournier found it enlarged in 15 out of 212 cases. 

The liver was enlarged in 25 cases. In one of my cases of late 
hereditary syphilis in a child eight years of age, post-mortem exam- 
ination revealed cirrhosis of the liver of the hypertrophic type. 
There were enlargement of the spleen, icterus, and ascites ; Hutchin- 
son's teeth were well marked, and there were also adenopathies and 
vasculitis. 

Fournier among others has described forms of idiocy and epilepsy 
of syphilitic origin, but there is great difference of opinion on this 
question. The theory of Parrot, that rachitis is the result of syphilis, 
is now generally abandoned. The deformities of the teeth which 
occur in late hereditary syphilis will be found fully described in the 
section devoted to Dentition. 

Congenital or Hereditary Syphilis. 

Congenital or hereditary syphilis results from the infection of the 
ovule or foetus in utero. This may occur in a number of ways, 
but in the great majority of instances it results from infection of the 
foetus through the father. The more recent the syphilis of the 
father, the more likely is the infection to occur. It is most certain 
to occur if both the father and mother suffer from recent syphilis at 
the time of conception. The father may at the time of insemination 
suffer from recent syphilis and the mother be healthy. Under such 
conditions the child is born syphilitic. The mother may not show 
any signs of active syphilis either during pregnancy or at any subse- 
quent period. The mother may suckle her offspring, which shows 
all the marks of active hereditary syphilis, without becoming infected, 
but the child will infect any strange nurse. The mother has during 
pregnancy acquired an immunity against the infection. This phe- 
nomenon, which is a matter of daily observation, was first brought to 



406 THE SPECIFIC INFECTIOUS DISEASES. 

the notice of the profession by the distinguished surgeon Colles, and 
has since become known as Colles's law. The longer the mother is 
subjected to the influence of the syphilitic virus, the more perma- 
nent does her immunity become. Thus a mother who has at first 
miscarried may eventually give birth to a living infant which bears 
the marks of syphilis. As the virus becomes weakened, the mother 
may bear an infant to all appearances healthy. In the interval, 
although repeatedly pregnant, the mother has shown no signs of 
active syphilis. 

If the father is healthy at the time of insemination and the 
mother the subject of recent syphilis, the infant will be born syphi- 
litic. On the other hand, if the mother contracts syphilis after 
conception, the father at the time of conception having been healthy, 
the infant may or may not be born syphilitic. The nearer the time 
of the infection of the mother to the end of her period of pregnancy, 
the more likely is the infant to escape (Monti, Zeissel, Hutchinson). 
Such an infant if born healthy may become infected in the ordinary 
way from the mother after birth. 

A father who has passed through the secondary manifestations of 
syphilis may in the late secondary period or tertiary stage fail to 
convey the poison in the sperma. The result will be an infant free 
from syphilis (Fournier, Neuman). Yet so far-reaching is the influ- 
ence of the syphilitic dyscrasia that such an infant, although born 
healthy and at no time showing signs of syphilis, may present certain 
signs, such as peculiarities of bone formation (teeth) traceable to the 
syphilitic virus (parasyphilitic). 

Exceptions to Colles's law occur, as is to be expected. Fournier 
has recorded cases in which mothers apparently immune have devel- 
oped signs of secondary syphilis after the birth of the infant. Finger 
has met cases in which tertiary syphilis developed in the mother sub- 
sequent to pregnancy without the occurrence in her of any of the 
signs of secondary syphilis. 

Of 218 mothers w^ho had borne syphilitic infants, Hochsinger 
found 72 who were free from manifestations of secondary or tertiary 
syphilis although observed for years. 

Morbid Anatomy. — In considering the pathology of hereditary 
syphilis, Hochsinger divides the cases into four classes : 

The first class of cases die in utero before the eighth month. 
Autopsies upon such foetuses show general parenchymatous involve- 
ment of the glandular apparatus with epiphyseal osteochondritis. 

The second class includes infants born living or dead before the 
end of pregnancy. They present at birth a papulobullous syphilide. 
In these cases diffuse parenchymatous changes are found in the viscera, 
and frequently marked epiphysitis. 

The third class comprises infants born living and without any 
exanthema, but which later develop an exanthema independently of 
visceral or bony changes. 



CONGENITAL OR HEREDITARY SYPHILIS. 407 

The fourth class comprises infants born without an exanthema, 
but having at birth marked visceral and bone-changes. 

Taking up in detail the lesions found in the various parts of the 
body, we find that the skin shows an increase in the thickness of the 
rete Malpighii, caused by swelling of the cells of the rete, serous 
infiltration of this layer, and an increase of the spaces between the 
cells of the rete. The horny layer of the skin is much thinned in 
comparison, although there is a constant throwing-off of the cells 
of this layer in lamellae. The epithelium of the sweat-glands is 
swollen and there is a small round-cell infiltration between the 
glands. There is a vasculitis of the small bloodvessels affecting 
the external coat chiefly. Pemphigus and bullae result from infiltra- 
tion of the rete and the lifting up and separation of the horny from 
the papillary layer by serum. 

The Lungs. — The changes in the lungs may be considered under 
two heads : 

First, the lungs of infants born dead or who have died soon after 
birth, are collapsed, devoid of air, hypersemic, and dark red in color. 
In rare cases the lungs may be diffusely whitish yellow in color, 
giving the appearance of the so-called pneumonia alba. The second 
class comprises infants that have breathed, and that show a gray or 
grayish-white discoloration of the lungs in places. There is residual 
air in the lungs, and they are denser and larger than is normal. 

Ziegler has shown that the changes in the lungs consist chiefly in 
an increase in the interalveolar connective tissue, the formation of 
new vessels, and vasculitis of the bloodvessels. In the majority of 
newly born infants the alveolar epithelium is but little affected. In 
pneumonia alba there is a proliferation of the alveolar epithelium, 
giving a peculiar appearance and color, hence the name. 

The Liver. — Changes in the liver are quite constant in hereditary 
syphilis. These may or may not be associated with enlargement of 
the organ. Out of 148 cases of congenital syphilis, Hochsinger 
found the liver enlarged in 46 ; in all but 2 the spleen also was en- 
larged ; in the severer cases the liver was markedly enlarged. 

The pathological changes in the liver have been described by 
Hudelo, Hochsinger, and Heller. There may be simply diffuse, 
small round-cell infiltration of the interstitial connective tissue, with 
inflammatory changes in the smaller arteries. The liver in these 
cases is not enlarged. In the cases presenting an enlarged liver 
there is interacinous proliferation of connective tissue, beginning at 
the periportal region and following the course of the bloodvessels. 
There is vasculitis, shown in a thickening of the adventitia of the 
bloodvessels. The parenchyma is degenerated. In other cases inter- 
acinous collections of small round cells are on gross sections of the 
liver seen as yellow pinhead-sized spots. These are called by Hoch- 
singer miliary gummata. Fully developed gummata of large size are 
very rare in the liver of infants affected with hereditary syphilis. 



408 THE SPECIFIC INFECTIOUS DISEASES. 

The spleen is in some cases enlarged to ten times its normal size. 
Gummata, single or multiple, occur, but are rare. In hereditary 
syphilis not only is the parenchyma increased, but also the connective 
tissue of the spleen. 

Kidneys. — In rare cases there are induration and contraction of 
the kidney. The parenchyma is retarded in development by intra- 
uterine syphilis and the connective tissue increased. 

The pancreas may be enlarged and infiltrated, the parenchyma 
hard, and the interstitial connnective tissue increased. There may 
be condylomatous ulcerations on the tongue, pharynx, and tonsil. 

According to Hochsinger, the glandular apparatus of the gut 
may show a diffuse small-cell infiltration, Peyer's patches may be 
infiltrated, and the vessels may be the seat of a vasculitis. The 
lymph-nodes are, as a rule, little changed except in cases with late 
manifestations. The thymus gland in cases of hereditary syphilis 
has been found to be the seat of cystic degeneration (Eberle, 
Ribbert), caused by the dilated epithelial spaces of the foetal 
thymus. 

Bone-changes. — The bone-changes in hereditary syphilis occur 
principally at that part of the bone between the epiphysis and 
diaphysis in the lower end of the femur, tibia, and radius. In the 
milder forms of bone-change there is, according to Ziegler, little real 
inflammation. There are irregularity in the deposit of lime salts 
and the formation of marrow-spaces. In severe forms there is a 
true inflammatory process. In the vicinity of the joint-cartilage, 
grayish-red, yellowish-white, or yellowish-green foci of osteomyelitis 
are found. The irregular deposit of lime salts and the formation 
of marrow-spaces are evidenced by reddish-yellow projections of mar- 
row-spaces into the adjacent proliferated cartilage. These give the 
epiphyseal junction a more irregular and widened appearance than is 
normal. Sometimes separation of the epiphysis at the junction of 
the diaphysis occurs. The above changes are frequent, although not 
constant. In the later stages of syphilis in children there are, as in 
the adult, caries, necrosis, and gumma formations in the long and 
flat cranial bones. 

Symptoms. — The symptomatology of hereditary syphilis varies 
largely with the class of cases. In some cases the foetus is expelled 
dead, bearing the marks of fully developed syphilis in the shape of 
skin, bone, and visceral lesions. In others the infant is born living, 
but presents a few very characteristic signs of syphilis, such as the 
presence of bullae or pemphigus either on the palms or on the soles 
of the feet. The vesicles may be filled with a purulent fluid. As 
a rule these infants are emaciated. In some cases the bridge of the 
nose is sharply depressed and forms a distinct angle with the carti- 
laginous septum (Plate XV.). This intra-uterine deformity in the 
newborn infant has been studied by Epstein. Such infants suffer 



PLATE XV. 




Congenital Syphilis, Showing nasal deformity. 
Newborn infant. 



CONGENITAL OH BEREDITARY SYPHILIS. 



409 



from a troublesome coryza and cannot breathe freely through the 
nose. They present enlargement of the liver and spleen, and there 
may be a few copper-colored discolorations on the skin of the fore- 
head and nose. The lips have a shiny, glossy appearance, and after 
a time may present distinct rhagades. Some days after birth there 
is a diffuse syphilitic eruption of papules or vesicopapules, with the 
so-called diffuse induration of the skin of the palms of the hand 
and soles of the feet, described by Hochsinger. Here and there 
discolored spots which were formerly mistaken for papules may be 
seen. The skin of the face may have a diffuse coppery color. 
Patches of discolored skin appear and become confluent, the coryza 
and rhagades along the lips and at the angle of the mouth become 
more marked, and the rhagades bleed easily. 

Fig. 80. 



1 


imi^ 


f 


- L 


i 

' H 








' -il 



Hereditary syphilis : rhagades and mucous patches of the lips. 

In another class of cases the infant is born well nourished and has 
a good color. Within from two to four weeks a general eruption of 
papules and vesico-papules appears. Some of the vesico-papules are 
purulent, and after bursting dry up, leaving the surface covered with 
crusts on a copper-colored base. In these cases the manifestations on 
the mucous membranes, including coryza, mucous patches, and rhag- 
ades are also gradually developed (Fig. 80). If the above symptoms 
are marked, we may find enlargement of the liver and spleen. I have 
seen the most marked signs of hereditary syphilis of the skin without 
the slightest enlargement of the liver or spleen. As a rule the arms 



410 



THE SPECIFIC INFECTIOUS DISEASES 



will present papules, which may ulcerate at the points of contact 
with adjacent surfaces of skin. The typical condyloma lata is not 
frequent in early hereditary syphilis. The nates have a coppery 
shining color, are cracked in places and diffusely indurated (Hoch- 
singer's induration). The trunk may present few symptoms. The 
bicipital glands are enlarged if the syphilitic exanthema is fully 
developed. The thighs show brownish, copper-colored patches. 
These patches give the skin a marbled appearance, which differs 
from that of the so-called healthy marbled skin in that the discolored 
areas are surrounded by normally colored skin, while in ordinary 
marbled skin the opposite condition obtains. On exposed areas, 
such as the knees, nates, soles of the feet, and palms of the hands, 
the skin is diffusely indurated. 

In a detailed consideration of the lesions, those of the skin are 
the first to engage attention. The most common forms of eruption 
are the papular or the papulopustular form of syphilide. This may 
be combined with the macular form ; in fact, it is common to find 
in the same case all forms in various stages of development. 

Fig. 81. 




Congenital syphilis : circinate syphilide of the nose. 



The papules occur on the forehead, palmar surface of the hands 
and plantar surface of the feet, and on the nates (Fig. 81). They 
show a distinct induration of the skin, are raised above the surface, 
and have a glossy, copper-colored appearance. On the nates or in the 
groin the papules may ulcerate ; very rarely these form condylomata 



> 

X 
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0. 




B '2 

0) 

u 


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Oh 



CONGENITAL OR HEREDITARY SYPHILIS. 411 

lata in the early periods of congenital syphilis. The condyloma 
is a feature of the later period of this disease. Macules develop 
within the first three months of life, and from the sixth to the tenth 
week are associated with seborrhoea. Infants thus affected are born 
with a peculiar anaemia, in which the skin has a cadaveric hue. The 
macules appear on the forehead and face as copper-hued spots, which 
increase in number until the skin has a general marbled appearance 
(roseola syphilitica). They then fade, leaving the surface covered 
with brownish-red areas. These persist around the alse nasi and 
the forehead for a long time, giving the face a peculiar dirty-yellow 
spotted appearance. 

The diffuse syphilitic infiltration of the skin has been studied by 
Hochsinger. It is not the forerunner or the sequence of any papular 
eruption. It appears in the third week in 50 per cent, of the cases, 
and reaches its height between the eighth and the tenth week. It 
first presents discolored areas on the palms and on the soles of the 
feet, on the nates, the calves of the legs, also on the cheeks and 
chin, where it forms rose-colored or copper-colored areas which 
coalesce. The soles and palms may appear diffusely red or bluish 
and glossy. The skin is diffusely thickened on the palms and soles 
and desquamates in lamellae. At the junction of the mucous mem- 
branes and skin fissures result on account of the thickening of the 
skin. The lips appear anaemic as a result of the infiltration of the 
mucous membrane, and are fissured. There are rhagades at the 
alae nasi. The rhagades at the angles of the mouth are covered 
with a bluish-white pellicle, and the surrounding skin is copper- 
colored. There are swelling of the nasal mucous membrane and a 
thin, purulent discharge mixed with blood. The hair falls out on 
account of the infiltration of the scalp ; the scrotum is thickened and 
fissured from the same cause. 

The blood shows all stages of anaemia, from the mildest to the 
grave pseudoleukaemic anaemia of von Jaksch, which some authors 
trace to syphilitic influences. 

The bones are affected with an osteochondritis, already described. 
This may appear in the first few weeks or at a much later period. 
It manifests itself by pain in moving the joints. The infant cries 
when handled. The mother notices that one arm lies motionless at 
the side, and that every attempt to move it causes pain. Parrot 
described this condition as a pseudoparalysis. At the junction of 
the epiphysis and diaphysis at the lower end of the humerus or 
radius the bone may be swollen and painful. As a rule, the process 
affects the upper extremity on one side only, but in severe cases 
both the upper and lower extremities may be involved. In some 
cases this symptom may be present without a skin eruption. The 
other conditions which simulate it are septic osteomyelitis involving 
the joints, scurvy, and severe rachitis. I have known instances 
in which prolonged observation was necessary to clear up the case. 



412 THE SPECIFIC INFECTIOUS DISEASES. 

A very characteristic but not common affection of the bones is 
the so-called dactylitis syphilitica (Fig. 82). This may appear as 
early as the fourth week, and may be associated with swelling of the 
epiphyses of the long bones. It consists of a fusiform swelling of 
the phalanges of one or more fingers. According to Taylor, this is 
primarily a gummatous infiltration of the skin, the periosteum, bone, 
and epiphyseal cartilage. In another form the periosteum and 
the bone itself are the seat of the gummatous inflammation, the 
epiphysis and the joint becoming involved later in the process. In 
neglected cases, fistulse and destruction of the joint may result from 

Fig. 82. 




Congential syphilis: onychia of all the nails ; dactylitis of the phalanx of the index finger. 
Infant, four months of age. 

necrosis of the epiphysis. The diagnosis of these forms of dactylitis 
from tuberculous spina ventosa is sometimes difficult, and often 
impossible without mercurial treatment. Cases of rachitis which 
involve the phalanges of all the fingers simulate very closely the 
above affection (see Rachitis). 

Syphilitic affection of the liver gives no symptoms. Henoch 
records cases in which icterus was associated with enlargement of the 
organ. Hochsinger denies the occurrence during the nursing period 
of any authentic case of syphilis of the liver with icterus or ascites. 

Somma, Fischl, and Kohts have described symptoms of cerebral 
syphilis in infants that were subjects of hereditary syphilis. Con- 



CONGENITAL OR HEREDITARY SYPHILIS 



413 



vulsions, hydrocephalus, epilepsy, and paralyses have been traced to 
the presence of gummous meningitis or sclerosis. That such changes 
occur as a direct result of syphilis at so early a period is doubted by 
Henoch. I have not seen manifestations of cerebral syphilis in 
infants. Henoch is also inclined to include Mracek's cases of 
hemorrhagic syphilis among the septic diseases of the newborn occur- 
ring in syphilitic infants. 

Antonelli in 1897 described changes in the fundus oculi of new- 
born syphilitic infants. These consisted of optic neuritis, retinitis 
vascularis, and retinochoroiditis. He believes these changes to be 
causative in the production of myopia and strabismus in such infants. 

The diagnosis of hereditary syphilis is not difficult in the vast 
majority of cases. If the foetus is expelled dead, it bears the marks 
of syphilitic infection, such as bullae and affections of the inter- 
nal organs. Maceration alone is not indicative of syphiKs. If 

Fig. 83. 




Hereditary syphilis : gummata of the cranial bones. Child, eighteen months of age. 

the infant is born living, the evidences of syphilis are sometimes 
very few and equivocal. After a few months the diagnosis will 
sometimes be difficult ; the eruption will have disappeared, leaving 
only an anaemia of uncertain origin, with a few discolored areas 
about the nasolabial folds and around the temporal region. There 
is a suspicious dirty-looking seborrhoea of the supra-orbital region. 
A rebellious anal eczema or copper-colored intertrigo which resists 
treatment should arouse suspicion. Pustular papules are not pathog- 
nomonic even if combined with joint-affections. A case came under 
my notice in which an infant had a varicella-like eruption with a 
painful swelling of the right elbow-joint. A diagnosis of epiphy- 
sitis syphilitica had been made and the eruption had been mistaken 



414 THE SPECIFIC INFECTIOUS DISEASES. 

for a syphilide. The color of the eruption was not that of a syphi- 
lids Expectant treatment and immobility of the joint proved, after 
a few days, that the case was one of varicella with the joint-compli- 
cation sometimes seen in that disease. 

In the diagnosis of late hereditary syphilis the symptomatology 
is of service. In cases with bone-lesions it is often very difficult to 
differentiate it from tuberculous affections (Fig. 84). An active course 
of treatment then becomes necessary, with a view to diagnosis. 
This is especially the case in arthropathies, and also in late forms 
of dactylitis. 

The prognosis as to life depends upon several factors. A breast- 
fed infant is more likely to survive than a bottle-fed infant. The 
possibility of complete restoration to the normal is slight. The 
majority of infants bear the marks of the disease into adult life, 
even under very favorable conditions of treatment and environment, 
and develop late in life the so-called late symptoms of hereditary 
syphilis. Some infants while progressing favorably under treatment, 
die suddenly without apparent cause; others remain stunted and 

Fig. 84. 



:^ 




Tuberculous aflPection of the bones of the hand simulating syphilitic disease. Child, sixteen 

months of age. 

delicate throughout childhood. Rachitis and its sequelae seem to be 
very prevalent among infants who are the subjects of hereditary syphilis. 
The treatment of congenital syphilis may be either internal, by 
inunctions or subcutaneous injections. I have found internal treat- 
ment to be the most satisfactory. The effects of mercury are not 
so injurious as is the case with the inunction methods. The drug 
employed was calomel in combination with the saccharated ferric 
carbonate (this was a favorite remedy of Widerhofer) : 

Calomel gr. i_ (0.01). 

Ferri carb. sacc. . gr. iij (0.18). 

• Ft. pulver. 



CONGENITAL OR HEREDITARY SYPHILIS. 41 5 

A powder of this size may be given every three hours or four ^-rmes 
a day. Some authors (Baginsky) prefer the protoiodide of mercury, 
s:rain ^ to |- (0.01 to 0.03). If there is intolerance to caromel, 
satisfactory results may be obtained by the use of Lustgarten's 
preparation of hydrarg. oxydulatum tannicum, in doses of grains ij to 
V (0.1 to 0.3), repeated every three hours or four times daily. 

If the rhagades, especially those about the anus, bleed t»r heal 
slowly, they should be stimulated with a weak solution of silver 
nitrate. Calomel should be dusted upon condylomata laisa three 
times daily. 

Baths of sublimate are recommended in severe cases of pemphigus, 
but it is not often necessary to resort to them. 

Infants in the nursing period do not bear inunctions well. I 
have seen several cases treated by this method which lost weight 
rapidly or died suddenly, and this has been the experience of others 
(Monti). The old method was to place grains viij to xv (0.5 to 1.0) 
of unguentum hydrarg. under the flannel abdominal binder daily, 
and allow it to be absorbed, or the same quantity of ointment was 
rubbed in daily on various parts of the body. 

Severe rhinitis is best treated by washing out the nasal passages 
once a day with a solution of corrosive sublimate (1 : 2000). The 
small glass syringe with a blunt soft-rubber nozzle is best for this 
purpose. After the syringing, unguentum iodoform, is applied to 
the interior of the nose by means of a camePs hair pencil. 

How long should treatment be continued? No matter what 
method of treatment is adopted, mercury should be administered 
until all discoloration of the skin has disappeared. To attain this 
result will take a varying length of time in different cases. After 
the skin is clear and the anaemia has disappeared, it is well to cease 
the administration of drugs and observe the patient for further symp- 
toms. Sometimes a patient will be brought to the physician for the 
treatment of a rebellious intertrigo long after all signs of general 
syphilis have disappeared. Such an intertrigo may have a copper 
color, and may ulcerate, the ulcers having a peculiar lardaceous 
appearance. In these cases, even if all other signs of congenital 
syphilis are absent, the internal administration of mercury gives 
brilliant results. 

The treatment of late hereditary syphilis will depend much upon 
the nature of the therapeutic measures adopted earlier in life. In 
the majority of cases, the subjects being in later childhood or ado- 
lescence, it is well to begin treatment by a full inunction course, 
conducted on the same plan as with adult subjects with acquired 
syphilis. In addition, if gummatous affections of the bones are 
present, and if as in one of my cases visceral lesions, such as enlarge- 
ment of the liver, have appeared, the patient is put upon gradually 
increasing doses of iodide of potassium. In one of my cases large 



416 THE SPECIFIC INFECTIOUS DISEASES. 

doses of iodide of potassium failed to relieve the intense headache. 
This patient married, and after having a miscarriage gave birth 
under specific treatment to a healthy infant. The treatment of 
acquired syphilis does not differ from that of congenital or late 
hereditary syphilis. 

XIX. ACUTE ARTICULAR RHEUMATISM. 

{Polyarthritis Rheumatica ; Rheumatic Fever.) 

Although acute articular rheumatism is still regarded by some 
authors as a constitutional disease caused by disturbances of nutri- 
tion which result in local manifestations, the general tendency is to 
regard it as an acute infectious disease. The infectious agent, 
whether bacterial or toxic, attacks the serous cavities, such as those 
of the joints, the pericardium and endocardium, and the pleura. 
The resemblance of rheumatism, especially in children, to the infec- 
tions is sufficiently great to warrant a serious consideration of this 
theory. Thus in septic endocarditis in children, as in the adult, 
there are symptoms of pain in the joints. Chronic cases of 
endocarditis of a rheumatic nature in course of relapse occasionally 
take a septic course. Certain diseases, such as erythema nodosum 
and peliosis rheumatica, in which the joint-symptoms are marked, 
are regarded as being caused by infection of a bacterial nature. I 
have lately seen such a case of peliosis. In other diseases, such as 
scarlet fever, measles, and varicella, there are joint-affections which 
are recognized to be of an infectious nature. Lastly, both American 
(Packard) and English writers have called attention to the well- 
observed clinical fact that there are forms of rheumatism and 
endocarditis which follow attacks of tonsillitis of the lacunar type 
or accompany them. It is true that the infectious agent, whether 
bacterial or toxic (Chvostek), is still to be discovered. Time may 
show that not one, but a variety of micro-organisms are capable of 
causing rheumatism of the acute articular type in a susceptible 
organism. Streptococci have been found in the exudate of the joints 
(Hlava). Staphylococci aureus, citreus, and alba have been found 
in the blood (Gutmann, Tizzoni, Bouchard). The pneumococci of 
Frankel and the Diplococcus tenuis have been found in the joints 
(Leyden). Singer has found similar micro-organisms in the urine. 

Heredity is among the predisposing causes. Children whose 
parents are markedly rheumatic, may suffer severely from the 
affection. Cold and exposure certainly predispose to the disease 
or precipitate attacks. The disease is common in countries such as 
England and America, in which climatic influences are favorable to 
its development, and is especially prevalent in the naoist and cold 
seasons of the year. 



ACUTE ARTICULAR RHEUMATISM. 417 

Age. — Rheumatism has been described as occurring in early 
infancy (Jacobi). I have published a case in an infant of nine 
months. Rauchfus, Chapin, and others have also described cases in 
infants. These cases were collected by Miller, who, with his own 
case (nine months), found in the literature only 19 authentic cases 
in nursing infants. Although rare in infancy, rheumatism is not 
uncommon in children from the fifth to the tenth year. The ma- 
jority of the cases of rheumatism occur between the tenth and the 
twentieth year. 

Sex. — Among adults, males are more subject to the disease. In 
children, however, although certain observers contend that it is more 
prevalent among girls, other statistics show that it has the same fre- 
quency of occurrence in the sexes. 

Symptoms. — Certain peculiarities, pointed out by Jacobi, seem to 
diiferentiate acute articular rheumatism of infants and children from 
the same affection in adults. But few joints are attacked. The 
pain and swelling are generally not very marked. The redness of 
the joint is slight or altogether absent. The temperature is rarely 
high. The smaller joints, such as the maxilla, sternoclavicular articu- 
lation, and those of the vertebrae, are rarely attacked. The larger 
ones, such as the ankle-, knee-, and wrist-joints, are most commonly 
affected. 

Cardiac complication is the rule. As Jacobi has pointed 
out, endocarditis is sometimes the first manifestation of the dis- 
ease. 

Clinical Types. — In infants and young children the first signs are 
swelling and pain in the affected joints. The infant in the nursing 
period cries, has fever, and is restless. On investigation it is found 
that the patient favors one extremity, and shrieks with pain when it 
is touched. Children of two and one-half years or more refuse to 
walk, and will complain of the affected joint, ankle, or knee. There 
will be fever and constitutional symptoms. The ankle, and in some 
cases the smaller joints of the foot are swollen. One of the knees, 
the wrist, and elbow may also be swollen, red, and painful. The 
fever rarely rises above 103° or 103.5° F. (39.4° C). In other cases 
there are fever and restlessness, and sometimes pains of an indefinite 
character in the joints. A history of pain may be elicited by care- 
ful questioning and examination. 

The physician may find an angina, slight or marked ; the heart 
may show signs of endocarditis of an acute type. There are pains 
in the joints but no true rheumatic swellings. The pains more 
closely resemble those in uncomplicated angina tonsillaris. In 
older children, a history of joint-pains with endocarditis may be 
obtained. In other cases, the pains in various joints are the only 
symptoms. There is no swelling or redness, and no endocarditis. 
Some cases have no fever. The classical cases, however, closely 

27 



418 THE SPECIFIC INFECTIOUS DISEASES. 

resemble those of the affection as seen in the adult. There may be 
premonitory symptoms, but as a rule the patient is brought to the 
physician with the enlargement of the joints fully developed. After 
the joints have become enlarged they may return to the normal in a 
few days, but may again be the seat of pain and swelling. The 
swelling in the joints of children does not persist as long as in the 
adult subject, and as a rule children are less disabled. In many 
cases there are gastric pains. The children do not show any greater 
tendency to perspire than adults. 

Endocarditis is usually a complication of rheumatism in children. 
Its absence is rare. Only 2 of 15 of my hospital cases during the past 
year were free from cardiac complication. The most common cardiac 
lesion is found at the mitral valve and is manifested by a single 
systolic murmur at the apex. Three of the cases showed the pres- 
ence of a double mitral murmur. Endocarditis sometimes does not 
reveal its presence by any symptoms, and is only discovered on a 
careful examination. In many of the cases there is also a pericardial 
friction first heard at the apex or base of the heart. The pericardial 
friction is more common in children than is generally supposed. 
The pericarditis frequently remains in the dry friction stage, and does 
not advance to effusion. Pleuritis and bronchopneumonia are among 
the less common manifestations. The endocarditis sometimes occa- 
sions pain and distress. The presence of endocarditis as an acute 
affection in first attacks of rheumatism has been dilated upon in the 
section on Endocarditis. 

Chorea. — The relationship of chorea and rheumatism has been 
discussed. I have seen a child of two and one-half years born of 
a rheumatic mother, develop first rheumatism and endocarditis, and, 
within a few days, marked chorea. On the other hand, in many 
cases of chorea, there is neither endocarditis nor a history of rheu- 
matism in children or parents. The statistics of chorea in hospital 
service show a greater frequency (39 per cent.) of cardiac disease with 
or without a history of rheumatism than the ambulatory cases. This 
is explained by the fact that only the severer cases of chorea come 
to the hospital. 

The prognosis of acute articular rheumatism in infancy is good 
as to life. On the other hand, it is a disease which is likely to recur 
and to be complicated by endocarditis. The latter fact should cause 
the physician to reserve any definite prognosis until the course of 
the disease has been carefully studied. The prognosis of rheumatic 
endocarditis can never be definitely made. All depends on the 
amount of damage done to the valves and the frequency of the 
recurring attacks. 

The treatment of acute articular rheumatism in children is not 
essentially different from that followed in the adult. I use salicylic 
acid, bicarbonate of sodium, salicylate of sodium, aspirin, and oil 
of wintergreen. 



OTHER FORMS OF SO-CALLED RHEUMATISM. 419 

The bowels should be kept open with an alkaline cathartic. The 
Carlsbad salt or Rochelle salt given daily is best adapted for this 
purpose. The patient is put on a milk diet ; fruit juices are allowed. 
The patient is kept in bed. The affected joints^ if painful, are either 
immobilized or wrapped in cotton. Some prefer to paint the joints 
with a solution of oil of wintergreeUj and then wrap them in cotton. 
Salicylate of sodium is given internally in doses of grains ij to v 
(0.12 to 0.3) according to the age. Young children are given a dose 
every three hours. Older children are given doses of grains vij to x 
(0.5 to 0.6). The effect is watched. Salol or salophen may be given. 
The salicylates sometimes not only act as irritants to the stomach, but 
also have no appreciable effect on the course of the disease. Aspirin 
has in my hands been useful in cases in which the salicylates were 
ineffective. In some cases I give bicarbonate of sodium in increas- 
ing doses until the urine becomes alkaline. Endocarditis is treated 
on the principles laid down in the section on that disease. While 
under treatment the patient is given alkaline waters. During con- 
valescence the various preparations of iron are of great value. The 
preparations of lithium are useful in cases in which there are 
indefinite pains in the joints. The carbonate is given in doses of 
grain j (0.06) three times daily. It is given in capsule to older 
children after meals. The method of treating rheumatic subjects 
by the occasional administration of salol or salicylates for months 
has been suggested. The salicylates upset the stomach, so that the 
alkalies alone are available. The patient is given grains v (0.3) of 
sodium bicarbonate twice daily every other day. Vichy water is used 
regularly. In some cases the tablets of vichy taken once or twice 
daily are of great value. 

Other Forms of So-called Rheumatism. 

{Rheumatoid Affections.) 

There are forms of joint-affection which it is not yet advisable 
to class with true articular rheumatism, but which are constantly and 
incorrectly called rheumatic. 

The gonorrhoeal form of rheumatoid affection is seen in infants 
and children who suffer from gonorrhoeal vulvo- vaginitis or ure- 
thritis (Hartley, Koplik, Moncorvo). It may be monarticular or 
many joints may be affected. It is not, as a rule, combined with 
endocarditis. I know of no such case in the literature. 

Peliosis. — Cases of so-called peliosis rheumatica closely resemble 
acute articular rheumatism. I have seen several in older children. 
In one, there were for weeks repeated painful swellings of the joints, 
with purpuric eruption about them. The gastric pains and critical 
sweats so often seen in rheumatism were present. These cases 
rarely present a temperature above 100.5° F. (38° C). They 
show no cardiac lesion. 



420 THE SPECIFIC INFECTIOUS DISEASES. 

Tonsillitis with Joint-pains and Endocarditis. — Under the 
proper beading I have referred to cases of tonsillitis with indefinite 
pains in the joints and complicated with endocarditis. 

Erythema Nodosum. — I have seen many cases of erythema 
nodosum in children. In all, the typical painful swellings on the 
anterior aspect of the tibia were present. There were also joint-pains, 
but in only 5 cases could I establish the presence of an endocardial 
murmur. I am therefore not willing to accept without reserve the con- 
tention of French authors that endocarditis is frequent in these cases. 

The so-called subcutaneous rheumatic nodules are seen in 
children less frequently in this country than in England. They 
occur in endocarditis, and were present in 20 per cent, of Coult's 
cases (Don kin). They may be present in the absence of fever or 
in the febrile stage of rheumatism. They may be minute or of 
the size of an almond. They appear in crops, and may alternately 
appear and disappear for weeks. The nodules occur about the 
joints, elbows, knees, patella, over ^the vertebrae and scapula, and are 
freely movable under the skin which is not discolored. I have seen 
them in a case of rheumatoid arthritis, and also in one of peliosis 
rheumatica. 

Muscular rheumatism is rare in infancy and childhood. 
Henoch describes cases of contracture of the muscles of the neck 
and of the nape of the neck. Among such contractures are forms of 
torticollis which are said to have a rheumatic origin. I have met 
many cases of torticollis in which with the contracture there was 
swelling of the cervical lymph-nodes. In such cases I have found 
eczematous affections of the scalp. It is possible that there was an 
acute infectious neuritis or myositis. There may, however, be cases 
resting on a purely rheumatic basis. All forms of torticollis due to 
hsematoma of the sternomastoid muscles or to cervical bone disease, 
glandular disease, or neuritis should be excluded before a definite 
conclusion is reached. Henoch also refers to contractures of the 
abductors of the thigh which are of rheumatic origin. I have 
never seen cases of the kind. 

References of Authorities for Collateral Reading. 

Anton W. : Die diphtherie der nase, Jena, 1897. 

Baqinsky, A.: ''Diphtherie," etc., Nothnagel's Spec. Path. u. Therap., 1898, Bd. 
ii., I. theil. 

Behring, E. : Therapy of Infectious Diseases, Parts I. and II., Berlin, 1900 
(allgm. therapie der infec. Krankheit). 

Blackader, A. D.: " Kelation between Human and Bovine Tuberculosis," Bos- 
ton Medical Journal, Dec, 1901. 

Blumer,G.: "Infection in Infants due to the Typhoid Bacilli," Trans. Amer. 
Med. Assoc, 1900. 

Celli, A. : Malaria, Vienna, 1900. Beitrg. zur exper. Therapie. 

Cornet, G. : " Die Scrofulose," Nothnagel's Spec Pathol., Bd. xiv. 

Councilman, Mallory and Pearce: Bacteriology and Pathology of Diphtheria, 
Sears Lab. Kep., 1901. 



REFERENCES OF A VTHORITIES. 421 

Councilman, Mallory and Wright : Report State Board of Health of Massachu- 
setts, 1898. 

Dennig, A. : Tuberculose in Kindesalter, 1896. 

Duel, A. R. : "Acute Otitis Media and Mastoiditis in Scarlet Fever and Measles 
and Diphtheria," Review of Reviews, 1901. 

Fielder, F. S. : " Vaccination," Medical News, 1901. 

Fournier, A.: Syphilis hereditaire tardive, Paris, 1886. 

Gaesler : Mittelorhe bei Scarlatina, 1900. 

Still : " Posterior-basic Meningitis," Journal of Pathology and Bacteriology, 1£C>^. 

Gershel, M. : "Value of Widal Reaction," etc., Med. Rec, Nov., 1901. 

Herzfdd : "Tubercul. Peritonitis," mittheilungen aus dem grenzgebiet der med., 
1901. 

Hochsinger, C. : Hereditare Syphilis, Vienna, 1898. 

Koplik: "Cerebrospinal Meningitis," Medical News, 1901. 

Koplik: '' Malaria in Infants and Children," New York Medical Journal, 1893. 

Koplik: "Measles Spots," Archives of Pediatrics, 1896. 

Macewen : Pyogenic Diseases of the Cord, 1893. 

Mattie, L. : Serotherapie preventive de la diph., 1901. 

Morse, J. L. : " Widal Reaction," Archives of Pediatrics, 1901. 

Ne.lter : "Meningitis," Transactions International Medical Congress, 1900. 

Nobling-Jankau : R. Fischl in Prophvlaxis der Krankheiten des Kindesalter, 
1900. 

Pearce, R. M. : "Scarlet Fever," Medical and Surgical Reports, Boston City 
Hospital, 1899. 

Pearce, R. M. : " Bac access sinuses scarl. and diph.," .Tournal Boston Society 
Medical Sciences, 1899. 

Renaud: These, Leucocytosis in Measles, Paris, 1900. 

Schmidt: " Rotheln," etc., Wien. klin. Wochenschr., 1900. 

Shaw, H. L. K. : "Prophylaxis Antitoxin," Albany Medical Annals, 1901. 

Slawyk : " Koplik's Spots," Deutsche med. Wochenschr., 1898. 

Gee and Barlow: "Cervical Opisthotonos, etc." St. Bart. Reports, 1878. 

Thursfield, H. : "Posterior Basic Meningitis," Lancet, 1901. 

Wentworth : "Meningitis in Infants and Children," Boston Medical and Surgical 
Journal, 1898. 

West, J. P. : "Glandular Fever, with Literature," Archives of Pediatrics, 1896, 



SECTION V. 

DISEASES OF THE DIGESTIVE SYSTEM. 
I. DISEASES OF THE MOUTH. 

Physiological Facts. — The mouth of the infant up to about 
the eighth month is devoid of teeth, and thus nature indicates 
that the infant is not prepared to masticate solid food. The 
salivary glands show very little activity in the first three months 
of infancy, the secretion of saliva at this time being small in 
quantity. 

In the newborn, before it has partaken of food, the reaction of 
the secretions of the mouth is neutral or slightly alkaline. Though 
an amylolytic ferment is present in the secretion of the parotid gland 
in the first days after birth (Zweifel), the function of this ferment is 
as yet a matter of speculation, inasmuch as the food of the newborn 
breast-fed infant contains nothing in which the action of such a fer- 
ment might be manifest. 

Of interest is the act of nursing, which in the infant takes the 
place of the process of mastication. 

Physiology of the Act of Nursing. — If an attempt is made to 
feed the newborn infant with fluids either from the spoon or 
pipette, there follows an abortive attempt at swallowing, accom- 
panied by choking ; it thus requires some skill and practice to 
induce the newborn infant to swallow fluids administered in this 
way. Not so with the breast. The newborn child instinctively 
takes the nipple of the breast, and nurses without the slightest 
education or preparation. The act of nursing, therefore, is purely 
reflex. 

Thompson has described the so-called lip reflex : If the infant at 
rest or sleeping is gently tapped or touched on the upper or lower 
lip in the neighborhood of the commissure, there follows first a 
reflex movement on the part of the lips. If they have been sepa- 
rated, they close and form themselves into a pouting position ; in 
other words, they purse themselves as if in readiness to take some- 
thing into the mouth. The breast-nipple, therefore, performs a 
function for the infant similar to that of the finger in producing this 
so-called reflex of the lip. The nipple once having touched the lips 
of the infant is received by the pursed lips into a funnel-shaped 
opening, and the lips grasp the nipple and some of the adjacent skin. 

423 



424 DISEASES OF THE DIGESTIVE SYSTEM. 

It is received between the hard palate above and the superior sur- 
face of the tongue below. The lower jaw aids in making the con- 
tact between the lips and the nipple complete. The act of nursing 
itself, therefore, is the establishment, first, of a negative pressure, 
caused by the act of suction, equal to 0.5 to 0.9 centimetres of mer- 
cury. This alone would not determine the flow of milk into the 
mouth of the nursling were it not for the muscular pressure from 
below of the lower jaw. The combined force of the negative pres- 
sure produced by the act of suction and the muscular pressure from 
below on the nipple as it joins the breast is equal to 4 centimetres 
of mercury. This has been shown experimentally to be quite suffi- 
cient to determine an equable flow of milk from the breast into the 
mouth of the nursling. It takes from three to four acts of suction 
and muscular pressure to fill the mouth sufficiently to cause one act 
of swallowing on the part of the infant. 

Characteristics of the Normal Mouth. — There are cer- 
tain localities of the mucous membrane of the mouth which are 
especially liable to aphthae or ulceration. Among these we must 
mention the mucous membrane over the hamular process of the 
palate bone, where it is normally paler than the surrounding tissue. 
This pale area on either side of the median line may be the seat of 
the so-called Bednar's aphthae. Midway in the raphe of the hard 
palate in most newborn infants are seen one or two, at most three, 
yellowish- white, sago-like objects ; these are called Epstein's pearls, 
because they were first described by this clinician. They are collec- 
tions of epithelial cells, the remains of embryonal formations. These 
epithelial pearls are quite susceptible to traumatism, and if injured 
in any way become the seat of ulceration. Laterally on the hard 
palate over the alveolar process, above and below the mucous mem- 
brane is thin and has a white reflex. Any slight traumatism in this 
locality may cause ulceration. The tonsils of the newborn infant 
are scarcely visible. The posterior pharyngeal wall is glossy, of 
a bluish-pink color. On closer examination of the fauces of 
infants, bodies resembling drops of dew or vesicles are seen just in 
front of the tonsil. These are collections of lymphoid tissue, and 
are normal to the infant's mouth. They may become inflamed and 
form aphthous ulcerations, and when so inflamed are called herpes 
of the tonsil. There are also visible on the soft palate of children 
minute miliary, transparent bodies resembling vesicles, which are 
likely to enlarge in any disease affecting the mucous membrane 
of the mouth, as in the exanthemata. These also are aggregations of 
lymphoid tissue. 

The bacterial flora of the mouth of the infant have been the 
subject of investigation by Lewkowicz, and include several, the strep- 
tococcic, micrococcic, and bacillary. Only the leading flora can be 
mentioned here : the pneumococcus, which is constantly present but 



NORMAL DENTITION. 425 

not pathogenic; the streptococcus, in long chains similar to the 
pyogenic variety but not pathogenic ; the Streptococcus salivse of 
Veillon, the Streptococcus aggregatus of Seitz, the Staphylococcus 
pyogenes albus, the Streptococcus intestinalis or enteritidis of Esch- 
erich, the Micrococcus candidans (Fliigge), the Bacillus acidiphilus 
of Moro, the most constant and frequent of the bacillary group ; and 
the pseudodiphtheria bacillus. There are also, strange to say, 
anaerobic bacteria to be found in the mouth of infants, the most 
important being the Bacillus bifidus communis of Tissier. In all 
there are 23 varieties of bacteria normal to the buccal cavity of 
nursing infants. 

Normal Dentition. 

The teeth, both milk and permanent, are contained in the so-called 
tooth-sacs, which are situated in the alveolar process of the upper 
and the body of the lower jaw. The formation of these sacs begins 
in the sixth month of foetal life, by a coalescence of the folds and 
papillae formed in the jaw. There are twenty milk teeth, and the 
sacs of the permanent teeth are situated against the posterior wall 
of the sacs of the milk teeth, and probably communicate with them. 
As a result of the growth of the roots of the teeth, the milk teeth 
are pushed through the cartilaginous border of the jaw and the 
mucous membrane, and thus appear externally. 

The eruption of the temporary or milk teeth begins about the 
sixth or seventh month with the lower incisors, and ends about the 
third year with the posterior molars. The eruption of the teeth, 
even in normal infants, varies within wide limits, some infants 
being precocious and others late in this process, without necessarily 
showing any signs of bone disease, such as rachitis. We might group 
the eruption of the milk teeth into five groups, as follows : The 
first group would include the two lower incisors, which erupt at 
from the seventh to the ninth month. There is then an interval 
of from three to nine weeks, when the second group, consisting of the 
four upper incisors, appears from the eighth to the tenth month. 
After this there is an interval of from six to twelve weeks, when 
the third group appears. This consists of the first molars and two 
lower lateral incisors, which erupt from the twelfth to the fifteenth 
month. An interval of three months then occurs, and the canines 
appear in the fourth group from the eighteenth to the twenty-fourth 
month. There is an interval of two months, and the four second 
molars appear. At the fifth or sixth year the third molar appears, 
and then the second dentition begins. 

As exceptions to the above order, we may have the two 
upper lateral incisors delayed until the sixteenth month ; the two 
upper incisors and the four posterior molars may be delayed as late 
as the thirty-sixth month. At the twelfth month an infant should 



426 DISEASES OF THE DIGESTIVE SYSTEM. 

have the four upper and two lower central incisors, with two lower 
lateral incisors coming. The lower incisors may not appear until the 
eighth or ninth month, and then be followed rapidly by others. I 
have seen several infants with one or two incisors at birth ; they, as 
a rule, were imperfectly formed and resembled canines. These pre- 
maturely erupted teeth should be extracted if they interfere with 
nursing and lacerate the nipple of the breast. In some cases the 
upper incisors may appear first, and rarely canines may appear before 
molars. 

The second dentition begins at the end of the sixth or seventh 
year with the eruption of the first molar behind the second tempo- 
rary molar. The milk teeth at this time loosen because their arte- 
ries become obliterated, the nerves disappear, the alveolar sacs 
enlarge, and they fall out or may become carious. The permanent 
teeth appear in the second dentition, as has been said, very much in 
the order that the milk teeth appear — the central incisors about the 
eighth year, the lateral incisors at the ninth year, and the last molars 
from the eighteenth to the twentieth year, or even later. 

Abnormal Dentition. 

Rachitis is a common cause of delayed dentition. Artificially 
fed infants are backward in cutting their first incisors. It is 
common to see bottle-fed infants cutting the lower anterior incisors 
at the ninth month. The infants may be in other respects normal. 
Rachitis affects the teeth of the first dentition mostly, but may influence 
the form and structure of the teeth of the second dentition. The 
teeth of the first dentition in rachitis are easily broken and are 
unnaturally white. In many cases the anterior incisors show an 
incurvation on the lower cutting edge, which is often mistaken by 
the inexperienced for Hutchinson's deformity. The first teeth in 
rachitis are easily eroded. It is not uncommon to see a rachitic 
infant with its whole dental system in process of decay. The per- 
manent teeth present abnormalities in inordinate size and longitudinal 
furrows. 

Syphilis. — The permanent teeth are affected by syphilis in a 
characteristic fashion. 

Hutchinson's teeth are so called because they were first described 
by Jonathan Hutchinson. They are the only teeth of the per- 
manent set which are pathognomonic of congenital or very early 
acquired syphilis (infancy) (Fig. 85). In a large experience with 
syphilis in infancy and childhood I have seen but few perfect examples 
of these teeth. The teeth presenting the deformity are the central upper 
incisors of the permanent set, and these only. '^ These teeth show 
a central single, rather broad notch.'' In this notch the dentine, 
lightly covered by enamel, is exposed. It is seen as a ridge in the 



ABNORMAL DENTITION. 



421 



incurvation. The teeth are shorter and broader than is natural, 
and almost always have their angles sloped off. They are thus 
narrower at their cutting edge than higher up. They are seldom 
or never of good color, and frequently are not placed quite straight, 



Fig. 85. 




Hutchinson's teeth in a boy, twelve years of age. 

but slope either toward or away from each other. Teeth which 
are the seat of erosion may resemble Hutchinson's teeth (Fig. 86). 
Fournier has described teeth in the temporary set which closely 




^^'YTf^' 



Permanent teeth deformed through stomatitis in early childhood, resembling Hutchinson's 
teeth. Female child, nine years of age. 

resembled Hutchinson's teeth. I have met an exquisite example 
of such teeth in an infant sixteen months old, the subject of 
syphilis (Fig. 87). 

In syphilitic subjects we find the following deformities in the 



428 



DISEASES OF THE DIGESTIVE SYSTEM. 



permanent teeth. 



Fig. 81 



|j*^P' 




These peculiarities are not characteristic of 
syphilis alone, but are found in those who 
are not syphilitic, but have suffered from 
stomatitis or dyscrasia of some kind. The 
changes are bilateral and symmetrical. 

Dental Erosions. — The most important 
erosions, such as those of Hutchinson just 
described, affect the central incisors. Other 
erosions give the teeth an incurvated ap- 
pearance on their cutting edge. In this 
incurvation is seen a supernumerary crown 
ribbed in a longitudinal direction (Figs. 88 and 89). The whole 
may be mistaken for Hutchinson's deformity. They result from 
malnutrition or stomatitis with faulty formation of dentine and 
enamel deposit in the eruptive period of the permanent teeth. The 
first molars show very characteristic deformities, which Fournier 



Central upper incisors of 
the first dentition resembling 
Hutchinson's teeth. Syphilis 
of the flat and long bones. 
Child, sixteen months of age. 



Fig. 



Fig. 89. 




MMKi 



''ipp'"||'iii 



'/iiiiip'' 



Upper central incisors, with erosions not 
syphilitic. 



Lower incisors, with erosions not syphilitic. 
Child, eight years of age. 

places next in importance to those of the Hutchinson teeth, but 
does not regard as pathognomonic of syphilis, although they are 
met in syphilitic subjects. This deformity of the first molars is 
shown in Fig. 90, taken from a child who showed other erosions, 
but gave no history of syphilis. I have seen these erosions very 
well marked in children who had positive syphilitic manifestations. 
The top of the crown is constricted, and there appears to be a 
double crown. Erosions are also seen in the canine teeth. 

Microdontism. — The teeth are quite small, but if cared for remain 
perfect in shape, pearly and transparent. They are seen in children 
whose parents may have suffered from syphilis. The children may 
also have obstinate eczema of the anus (parasyphilitic). Micro- 
dontism may occur also as a result of any non-syphilitic dyscrasia. 

Dental infantalism, described by Fournier, occurs in children 
who are syphilitic. Small teeth presenting erosions are interspersed 
among teeth which are normal in size and shape. 



PATHOLOGY OF DENTITION. 



429 



Amorphism, or the tendency of a tooth, such as the incisor, to 
take the shape of a canine, has been noted by Fournier. I have 
also met with cases of this deformity in congenitally syphilitic chil- 
dren. It is seen in children who have had syphilis, but may be 
met with in those who have no such history. 

Children, subjects of syphilis, do not always present deformi- 
ties of the teeth. In a girl of fourteen years, who gave a history of 
infantile syphilis, and who had late manifestations, such as gummata 



Fig. 90. 



Fig. 91. 




Erosion of molars, not nec- 
essarily syphilitic. 




Molar tooth, showing erosion at 
crown. Boy, twelve years of age; 
same patient as with Hutchinson's 
teeth. 



in almost all the bones, joint-affections, and gummata of the liver, 
the teeth, both upper and lower, were normal, of great beauty, and 
well preserved. 

Pathology of Dentition. 

The period of infantile dentition is one of great physiological 
activity and growth. The organism is forming at this time. 
The nervous system is in a condition of instability. The gut is 
exposed to all varieties of infection, and is very susceptible to 
them. During this period the infant or child suffers from a number 
of diseases and exhibits a variety of symptoms which in former times 
were difficult of interpretation. With advancing knowledge and the 
possibility of making more accurate diagnoses than were formerly 
feasible, the diseases incidental to dentition have become more a 
matter of speculation. There are clinicians of note who still believe 
that irritation of the trigeminal branches by an erupting tooth may 
cause reflex eclampsia. It is difficult, and not necessary, to pass 
here on the status of that section of infantile pathology which 
treats of the disorders incident to dentition. In the presence of 
mystifying symptoms the physician should make a very careful 
examination, in order to make the diagnosis. Clinical observation 
of a case for a few days, and accurate registration of the pulse, 
respiration, and temperature every three hours, may show that the 
diagnosis of dentition must give way to something more tangible. 

Should the Gums be Incised ? — I have often found the tooth- 
sacs to be swollen and the seat of painful distention just before the 
eruption of the teeth. In one case the tooth-sac was distended by a 



430 DISEASES OF THE DIGESTIVE SYSTEM. 

hemorrhage into its cavity. Under these conditions I have never 
yielded to the entreaties of the mother to lance the gums. I have 
seen no ill effects result from this laissez faire method. Very painful 
ulcerations result from friction, and uncontrollable hemorrhage may 
follow incision. In cases in which the sacs are distended, the func- 
tions of the stomach and gut should be kept normal, in order that, 
complications may not be added to existing conditions. In rare 
cases I have seen suppuration in the tooth-sac, and have incised. 
In some cases of scurvy the tooth-sacs are distended and bluish 
in appearance. Treatment of the scurvy improves this condition. 

Ulcerations or Erosions of the Angles of the Mouth. 

(Fr., Perleche; Ger., Faule Ecken.) 

Definition. — This is a form of non-specific ulceration or rhagade 
occurring at the corners of the mouth, affecting the vermilion border 
of the mucous membrane. 

Occurrence. — This infection is seen in children who present 
other signs of malnutrition, such as scrofulosis or lymphatism. 
They are anaemic, suffer from nasopharyngeal catarrh or skin erup- 
tions, and live in unhygienic surroundings. The disease is seen in 
children under two years of age, and mostly beyond that period. 
The disease is confined to the corners of the mouth, and may be 
strictly limited to them, though the author has often seen it com- 
bined with erosions of the alse nasi. 

Symptoms. — These erosions, fissures, or rhagades consist of 
lineal ulcers of the corners of the mouth, which may have a red 
base and elevated borders, or the base and borders may have a 
bluish tinge, resembling mucous patches. In these children the 
question of diagnosis of these rhagades from those due to syphilis 
is constantly arising. The induration of the base of the ulcer which 
is present in syphilis is absent in the non-specific rhagade. The 
surface of the ulcer has a more lardaceous appearance in syphilis as 
a rule, the lips are involved, and there are mucous patches else- 
where. 

The infection which we are describing is found isolated and lim- 
ited to the corners of the mouth. The borders of the rhagade may 
be surrounded by minute pustules. The infection is symmetrical, 
involving both sides of the mouth. It is not painful unless the 
mouth is put on the stretch or acid substances applied to the base 
of the ulcer. In other cases the borders of the rhagades are raised 
and indurated. I have seen a large number of these rhagades ; 
some, at least, so closely resembling a syphilitic lesion as always to 
warrant a careful exclusion in each case of this affection. 

Diagnosis. — The diagnosis offers no difficulty, though it is an 
affection which rarely comes to the physician to be treated as an 



BEDNAE'S APHTHA. 



431 



isolated disease, and is generally met in combination with other dis- 
eases. I have seen it in children suffering from typoid fever. The 
disease may be mistaken for diphtheritic infection, inasmuch as in 
some cases the base of the rhagade is covered by a pseudomembra- 
nous, whitish deposit. The culture tube will decide the true nature 
of the lesion in such cases. 

Course. — The duration of the disease extends over a period of 
two or three weeks ; if untreated, it usually becomes chronic. I 
have succeeded in curing these rhagades by touching them once 
daily with a 10 per cent, solution of nitrate of silver, and then 
applying the ointment of red oxide of mercury. Another remedy 
is the application of a solution of corrosive sublimate (1 : 2000). 

Bednar's Aphthae. 

Bednar's aphthae, named after the distinguished Viennese pedi- 
atrist who first described them, are two symmetrical ulcerations over 
the hamular process of the palate bone, seen in the newly born or 
very young infant (Fig. 92). In a large number of cases they are 
the result of traumatism. The finger of the nurse impinges on the 
processes of the palate bone when it is introduced into the mouth, 
and abrades the epithelium. Any bacteria which may be present in 
the mouth or on the finger thus gain foothold and ulceration results. 



Fig. 92. 




View of the hard and soft palate. Lateral ulcerations— so-called Bednar's aphthae. 

Epstein has shown that in the newly born infant such ulcers may be 
the starting-point of a general sepsis. 

The infant may refuse to nurse, or if it does attempt to do so, 
the pain caused by the act of suckling causes it to desist. There 



432 DISEASES OF THE DIGESTIVE SYSTEM. 

may be intestinal disturbance, manifested by greenish stools and 
caused by infection of the gut by the bacterial flora of the ulcera- 
tions. 

Treatment. — The ulcer should neither be washed nor trauma- 
tized. The rest of the mouth and tongue should be washed gently 
twice daily with a saturated aqueous solution of boric acid. The 
ulcers should be touched once or twice a day with a 10 per cent, 
solution of silver nitrate applied with a small piece of cotton on an 
applicator. 

Sprue. 

( Thrush ; Muguet (Fr.) ; Soor (Ger.).) 

Sprue is a parasitic growth on the mucous membrane of the 
buccal cavity of the newborn or very young infant. It may spread 
to the nose in cases of cleft palate ; in other cases it may spread to 
the pharynx, larynx, oesophagus (Parrot), and even to the stomach 
(Parrot, Henoch, Northrup). The latter situation is not favorable 
to its growth. The parasite has been found in the movements of 
infants suffering from the disease. 

Nature. — Sprue is one of the mould fungi. Its classification by 
various authors varies with the species examined. Older authors 
classed sprue with the oidium as Gidium albicans. Rees, Grawitz, 
and Kehrer classified it as a Mycoderma albicans, consisting of 
conidia and mycelia. Plant classifies it as a common mould fungus 
(Monilia Candida). 

In the early stages it presents large or small irregular whitish 
masses. These may at first be very minute, covering only the sum- 
mits of the papillae of the tongue. Gn the buccal mucous mem- 
brane they may be as large as a pin's head or coalesce into masses 
resembling curdled milk. They may be seen on the roof of the 
mouth, on the soft palate, tonsils, and posterior pharyngeal wall. 
If the affection is progressive, the tongue and inner surface of the 
cheeks become coated with a white closely adherent pellicle. In 
neglected cases the sprue may be of a yellowish color if sarcinse are 
present, or blackish or grayish in hue if other fungi have obtained 
lodgement. Considerable force is requried to dislodge the growth 
from the mucous membrane, and the operation will cause bleeding 
and considerable pain and traumatism. 

Occurrence. — The organism is introduced into the mouth from 
without. It is present in the vaginal secretions of the mother, and 
has been found on the breast nipple. An abrasion of the mucous 
membrane must exist in order that the fungus may obtain lodge- 
ment. It is therefore found in infants whose mouths have been 
harshly washed with unclean fingers or into whose mouths unclean 
breast or bottle nipples have been introduced after harsh washing. 
The fungus having gained access to the cement-substance between 



SPRUE. 433 

the epithelial cells, proliferates into the deeper layers of epithelium, 
and may even invade the underlying connective tissue. Sprue carries 
with it any other bacterial flora which may be present in the mouth. 
A perfectly normal mucous membrane is not vulnerable to sprue. 
The sprue conidia and mycelia are found in the secretions of the 
mouth of the normal baby. Sprue is seen chiefly in infants whose 
health is below the average, who are inmates of institutions, or who 
have been in unhygienic surroundings. 

Symptoms. — The local symptoms are due to the presence of the 
growth. In mild cases the patches are few in number and very 
minute. In neglected cases not only is the whole mouth the seat of 
the disease, but also evidences of infections of a pyogenic nature 
occur in the form of erosions of the buccal mucous membrane, 
yellowish plaque-like ulcerations and fissures which bleed easily. 
There is also dryness of the mucous membrane which has not been 
attacked or which has been freed from the fungus. Sprue, in 
fact, causes distinct reaction of the healthy mucous membrane in 
the vicinity of its invasion. Infants, even in the early stages, suffer 
from mild disturbances of the gastro-enteric tract, manifested by 
vomiting and greenish movements. In neglected cases marantic 
symptoms are also present. Older writers (Parrot) believed sprue 
to be a causal factor in athrepsia. It is simply regarded as a 
complication. 

That pain is felt is evinced by the lack of desire to nurse the 
breast. A febrile movement occurs if the intestinal tract is in- 
volved. 

Treatment. — Prophylactic. — Everything that is introduced into 
the mouth of the infant should be scrupulously clean. If the infant 
is breast-fed, the breast nipple should be cleansed before and after 
nursing with a pledget of cotton moistened with boric acid. The 
infant's mouth should not be cleansed after nursing. In cases 
in which the roof of the mouth has been carelessly cleansed 
there are not only the aphthae of Bednar, but also sprue and 
other aphthae in the median line as a result of traumatism to 
Epstein's pearls. If infants are fed articially, the nipple of the 
nursing-bottle should be boiled in soda solution once. If these pre- 
cautions are carefully observed, and unclean fingers never intro- 
duced into the infant's mouth, sprue will rarely if ever occur. The 
normal epithelium and normal secretions are safeguards against the 
fungus. 

Curative. — The growth should be removed by cleansing the 
mouth gently three times a day with a saturated solution of boric 
acid. The utmost gentleness should be used. Even in mild cases 
the removal of the sprue may extend over a number of days, 
because the parasite quickly reproduces itself. I use one piece of 
absorbent cotton for the roof of the mouth, another for the tongue, 
28 



434 DISEASES OF THE DIGESTIVE SYSTEM. 

and another for the cheeks and lips. If it can be avoided, the 
mucous membrane should not be caused to bleed. If aphthae exist, 
they should be touched lightly with a 2 per cent, solution of silver 
nitrate. The bowels should be opened by an initiative mild cathartic. 
Everything should be scrupulously clean. The severe cases, in 
which there is a septic condition due to extension of the sprue to 
the gastro-enteric tract, occur chiefly in foundling asylums. The 
infants die of septic infections. In private practice the prognosis 
is good if the case is seen early and correctly treated. Baginsky 
recommends potassium permanganate (1 : 150) ; others recommend 
corrosive sublimate (1 : 2000), but boric acid will be found to be 
equally satisfactory. 

Henoch describes cases of sprue of the stomach. This is admit- 
tedly rare, and occurs in the form of slightly prominent plaques. 
Parrot describes sprue of the gastric mucous membrane as not infre- 
quent. 

Aphthous Stomatitis. 

{Stomatitis Aphthosa.) 

In this condition there are formed on the soft and the hard palate, 
the mucous membrane of the gums and tongue, and on the inner 
surface of the lips and cheeks, small round yellowish superficial 
ulcerations. These ulcerations, which vary in form and number, 
may coalesce and form irregular plaques. It is a question whether 
the ulcerations are the remains of vesicles which have burst, thus 
exposing an ulcerated base, or whether they are primarily ulcers. 
I am inclined to the former view, for in the so-called herpetic 
aphthae of the tonsils the natural development of the aphthous 
ulcerations can be observed to advance from the vesicular to the 
ulcerative stage. This condition is very common in infancy and 
childhood, and according to Monti is most frequent between the 
first and the third year. 

The etiology is still obscure. Some authors consider aphthous 
stomatitis an acute infection derived from the gut, possibly caused 
by toxins generated in contaminated milk (Forcheimer, Ritter, 
Kmeriem, Schamtyr). Others, basing their opinion on bacteriologi- 
cal studies, regard it as a purely local affection. The clinical course 
of the disease tends to support the former view. It has been com- 
pared by Forcheimer and others to the so-called foot-and-mouth 
disease of cattle. 

The condition may occur idiopathically or may complicate intes- 
tinal infection, the exanthemata, bronchitis, tonsillitis, and pneu- 
monia. Some authors believe that the affection may be communi- 
cated to others by the secretions of the mouth. 

Bacteriology. — The forms of bacteria most commonly found in 



lOXIC SIOMATITIS. 435 

the ulcerations are the various streptococci and staphylococci 
(Jadassohn). Bernabei has found the pneumobacillus of Fried- 
lander. As these bacteria are present in the normal secretions of 
the mouth, it is doubtful whether they bear a causal relation to the 
condition. 

Symptoms. — These aphthae vary from the size of a pin's head to 
that of a split pea. They are invariably surrounded by an areola 
of inflamed mucous membrane. The outline of the ulceration may 
be round or irregular ; as a rule the ulcerations are superficial. At 
the line of junction of the teeth and gums they may show a ten- 
dency to bleed if touched. There is considerable pain, with saliva- 
tion, and in young infants also a distinct febrile condition and green 
diarrhoeal movements. In other cases there may be an accompany- 
ing angina with swelling not only of the lymph-nodes at the angle 
of the jaw, but also of those underneath the jaw. In addition there 
are loss of appetite, and restlessness at night. 

Course. — In well-nourished infants and children the tendency is 
to limitation of the aphthae and spontaneous recovery within three or 
four days. In marantic or badly nourished children in unhygienic 
surroundings, the aphthae are likely to spread, the ulcerations pre- 
senting the appearance of a mixed infection. Such cases are difficult 
to control. As a rule, however, the disease runs its course without 
leaving any lasting ill results. 

The treatment of the cases in which the ulcerations or aphthae 
remain discrete and in which mixed infection does not occur is 
begun with a saline cathartic, such as magnesia, or a dose of calomel. 
The mouth should not be washed. Careless attempts to cleanse the 
mouth are likely to cause the aphthae to coalesce and spread, and 
also to cause intense pain. I administer a small dose of ferric 
chloride, made up with glycerin, every three hours. In most cases 
this will suffice. The use of potassium chlorate should be avoided 
with infants. If the edges of the gums adjacent to the teeth are 
affected, the teeth should be gently washed three times daily with a 
weak solution of tincture of myrrh or a saturated solution of 
boric acid. If the aphthae coalesce, they should be touched once 
daily with a 2 per cent, solution of silver nitrate. With intractable 
young children, care should be taken in washing the mouth not to 
traumatize the unaffected mucous membrane. 

Toxic Stomatitis. 

I have seen a number of cases of stomatitis caused by irritant 
poisons, such as potash and ammonia. The children so affected had 
attempted to drink a solution of potash or ammonia from a bottle 
left within their reach. 

The symptoms were purely local. The mucous membranes of 



436 DISEASES OF THE DIGESTIVE SYSTEM. 

the lips had a characteristic oedematous, swollen, and transparent 
appearance, the buccal mucous membrane and the tongue were pale 
and oedematous, and the papillse were erect and transparent. 

The treatment was expectant. A mixture containing bismuth 
subcarbonate seemed to give most relief. On subsidence of the 
oedema the mucous membrane presented a dry appearance. Some- 
times small aphthous ulcerations appeared, which healed under ap- 
plications of a 2 per cent, solution of silver nitrate. 

In one case, five years of age, symptoms of oesophageal stricture 
were present three months after the ingestion of the irritant. Strict- 
ures of the oesophagus are more common after the ingestion of potash 
or lye solutions than after corrosion by ammonia. 



Ulcerative Stomatitis. 

{Stomatitis ulcerosa; Stomaeaciz ; Ger., Mundjdule.) 

Ulcerative stomatitis is a disease of the mucous membrane of the 
mouth, gums, and tongue, which is characterized by ulceration with 
a fetid odor. 

The etiology is still obscure. Friihwald and Bernheim found 
bacilli and spirochsetse (spirilla) in the ulcers. The fetid odor of 
the breath was reproduced in the cultures of Bernheim. The bacillus 
is lanceolate in form and resembles the diphtheria bacillus. These 
bacilli and spirilla are probably identical with those described in 
1896 by Vincent as occurring in hospital gangrene. 

The affection is most common between the fourth and the eighth 
year. The period of infancy seems to be exempt, in my opinion 
because of the absence of teeth. It occurs in children who have 
been neglected or who have lived in unhygienic surroundings, and is 
therefore very common in clinics and dispensaries. In the milder 
forms there is a line of yellowish ulceration along the margin of the 
gums at the point of contact with the teeth, and the adjacent mucous 
membrane is red and inflamed. When the gums are touched either 
in washing or in examination, bleeding occurs. There is a fetid 
odor of the breath, the tongue is coated ; some children have pain 
and loss of appetite, and a slight febrile reaction. In the severer 
cases there are deep ulcerations along the margins of the gums, 
which bleed on the slightest provocation. Ulcers with a greenish- 
yellowish base are seen along the border of the tongue and beneath 
it. In these cases the lymph-nodes beneath the body of the jaw are 
enlarged and painful as a result of the infection. The salivation, 
pain, and local disturbance are considerable, and the fetor is marked. 
The buccal mucous membrane at the points of contact with the 
teeth may be deeply ulcerated, indurations of the tissues of the 
adjacent mucous membrane being also present. Small particles of 



GONORRHCEAL INFECTION OF THE MOUTH. 437 

necrotic tissue are seen to flow away in the saliva. So great is the 
pain that some children refuse to open the mouth or partake of food. 
I have seen the teeth become loose and necrosis of the alveolar 
process occur in places. Under the latter condition there is much 
swelling of the tissues above and beneath the jaw (lymph-nodes). 
The tonsils may also be the seat of ulceration of the same character 
as that occurring at the lateral margin of the tongue. 

Treatment. — Cleanliness is the first step toward lessening the 
intensity of the inflammation. The mouth is washed every three 
hours with a solution of potassium chlorate, made by adding a tea- 
spoonful of the saturated solution to a small glassful of water, or 
with a 0.5 per cent, solution of formalin. Internally, liberal doses 
of ferric chloride, made up with glycerin and water, have given the 
best results. If there are extensive ulcerative processes along the 
gums, the line of ulceration is gently touched once a day with a 10 
per cent, solution of silver nitrate. In addition, the patient must 
have an abundance of fresh air, and is given a nutritious fluid diet, 
with fresh fruits and a small allowance of wine. 



Gonorrhoeal Infection of the Mouth. 

This affection, sometimes called gonorrhoeal or blennorrhoeal stom- 
atitis, is an infection of the mucous membrane of the mouth by the 
gonococcus of Xeisser. Infection occurs only in places where the 
mucous membrane has been injured. There may be an associated 
gonorrhoeal infection of the eyes or the vulva and vagina. The 
infection may be introduced into the mouth by the fingers of the 
nurse or mother. If the mother is suffering from gonorrhoea, infec- 
tion may occur at the time of birth or subsequent to parturition. 
The cases thus far reported (E-osinski, Kast) have developed from 
two to thirteen days after birth. 

Symptoms. — The constitutional disturbance is slight ; there is 
no fever, no pain, and no interference with suckling. The lesions 
occur on those parts of the hard palate most likely to suffer from 
traumatism and subsequent infection — the parts favored by Bed- 
nar's aphthae, the median raphe in the alveolar processes of the hard 
palate, and the anterior two-thirds of the tongue. Inspection reveals 
yellowish-white patches, due to infiltration of the superficial epithelial 
layers of the mucous membrane with inflammatory products. There 
is no pseudomembranous formation, but a pultaceous thickening. 
There is little tendency to spread, and no inflammatory reaction of 
the adjacent mucous membrane. The discharge is so slight that the 
saliva remains clear. 

Examination of the secretion from the patches on the hard 
palate (which are generally symmetrical) and on the tongue reveals 
the presence of abundant gonococci not only on the surface, but also 



438 DISEASES OF THE DIGESTIVE SYSTEM. 

invading the mucous membrane along the cement-substance between 
the epithelial cells. The infection differs from that seen in adults 
(Cutler), in whom great constitutional disturbance and severe inflam- 
mation of the whole mucous membrane of the mouth are combined 
Mdth a profuse ichorous buccal discharge and with pain. The ten- 
dency is toward rapid recovery. 

The treatment is limited to the enforcement of strict cleanliness, 
and to local applications of weak solutions of silver nitrate (2 per 
cent.). The mouth may be washed twice daily with a solution of 
protargol. 

Pseudodiphtheritic Stomatitis. 

This form of stomatitis was first accurately described by Epstein. 
It is seen in newborn infants who have sustained a traumatism of 
the mucous membrane of the mouth. An infection of the injured 
membrane with streptococci results in the formation of a membrane 
resembling that seen in true diphtheria. These cases occur in found- 
ling-hospitals and amid unhygienic surroundings. The pseudo- 
membrane is of a greenish-yellow hue, and may spread over the 
hard and the soft palate, the tongue, and the pharynx. It may 
involve secondarily the entrance to the larynx, as happened in the 
cases of Epstein, and the epiglottis and oesophagus as well. Gastro- 
intestinal symptoms and secondary septic pneumonia are developed. 
The temperature may, as in other cases of sepsis, be normal, or even 
subnormal. As a rule, the lymph-nodes are not enlarged. The 
condition must be differentiated from sprue and aphthous stoma- 
titis. Aphthous stomatitis does not show any pseudomembraue ; 
microscopical examination will aid in differentiating this disease from 
sprue. 

Treatment. — Inasmuch as these cases are of septic origin, their 
course is progressive. On the other hand, small patches of mem- 
brane may be limited by applications of a 10 per cent, solution of 
silver nitrate. The membrane should not be peeled off, nor should 
the mouth be washed out with the finger. Antistreptococcic serum 
is of no use in these cases. 

Noma. 

{Cancrum Oris.) 

Noma is a specific bacterial affection which attacks the tissues of 
one or both sides of the face, resulting in gangrene and destruction 
of the soft and hard parts. Babes and Zambolovici differentiate it 
from all other forms of gangrenous stomatitis and gangrene, such as 
those described by Henoch as occurring on the vulva. 

The etiology is still obscure. Investigations thus far tend to 
show that several conditions clinically similar have been found to 



NOMA. 439 

have a diverse etiology. Babes and Zambolovici isolated a very 
minute bacillus, and by inoculation experiments in animals produced 
typical noma. They found that this bacillus extends through the 
mucous membrane of the mouth, especially that of the gums. 
Accompanying it are a large number of streptococci, spirochsetse, 
and other bacilli. The latter play an active secondary role in the 
production of the gangrene. Gangrene is caused by an over- 
whelming bacterial invasion of the tissues. The toxins produced 
cause death of cell-life and necrosis in mass. In another set of 
cases, Walsh found the bacillus of diphtheria. These cases would 
appear to correspond to those published by Freimuth and Pe- 
truschky, who found a bacillus identical with the diphtheria bacillus 
in cases of noma of the vulva. 

The greater number of cases of noma occur after measles. It 
may follow any of the exanthemata, typhus, typhoid fever, or 
any disease through which the power of resistance to infection is 
lessened. 

Symptoms. — Henoch and Baginsky hold that in many cases an 
ulcerative stomatitis has preceded the main aifection. The disease 
begins on the mucous membrane and invades the cheeks from within. 
Henoch alone has seen it begin from without in the form of a phleg- 
mon of the cheek. It is first seen as a small ulcer with a blackish- 
gray base on the buccal mucous membrane opposite the teeth, or it 
may begin as a vesicle with serosanguinolent contents. After a 
period of time varying from a few hours to three or seven days the 
tissues of the cheeks become brawny and oedematous, the oedema 
involving the eyelids and lips. A dark, livid area finally appears 
on the corresponding exterior surface of the cheek. This area 
becomes black and gangrenous. Perforation and spreading of the 
gangrene rapidly result. The jaw may necrose and the teeth fall 
out. The process may spread downward along the neck, involving 
the shoulder in an oedematous, emphysematous, gangrenous mass. 
The indurations of the tissues of the cheek occurring in many forms 
of stomatitis ulcerosa should not be confounded with this affection ; 
in these forms of induration gangrene is absent. In all cases of 
noma a marked gangrenous odor pervades the atmosphere about the 
patient. 

The general condition of many cases is astonishingly good at 
first. The children seem unconcerned, and sit up in bed and play. 
The organism finally succumbs to the toxaemia accompanying such 
extreme destruction of tissue. There may be a febrile movement 
(103° to 104° F., 39.4° to 40° C). The swallowing of gan- 
grenous products in some cases causes an intensely prostrating and 
uncontrollable diarrhoea of a septic character. There is little or no 
pain. Death results within two or three weeks, either through 
general toxaemia and heart failure or complicating pneumonia. 



440 DISEASES OF THE DIGESTIVE SYSTEM. 

Occurrence and Prognosis. — From a study of the literature, 
noma is found to occur most frequently between the second and the 
seventh year. The mortality is very high — fully 75 per cent. 
(Woronichin). 

Treatment. — The most diverse methods have been employed in 
an endeavor to arrest the progress of the affection. To support the 
strength of the patient is the first consideration ; careful ventilation, 
antiseptic and deodorizing solutions to mask the gangrenous odor, 
good food, and wine, are all of service. 

The local treatment varies. Some authors advise dusting iodo- 
form on the gangrenous area ; others advocate the use of caustic 
zinc pastes in order to determine the line of demarcation between 
the gangrenous and healthy tissues. The Paquelin cautery with 
knife-blade attachment has been employed to remove the gangrenous 
tissue. Solutions of boric acid, thymol, and salicylic acid, should 
be freely employed to keep the mouth and parts clean. 

In those cases, probably a distinct set, in which the bacillus of 
diphtheria is found, the antitoxic diphtheria serum should be injected 
in proper doses. 

II. DISEASES OF THE TONGUE. 

Congenital Anomalies of Size. 

{3Iacroglossia.) 

The tongue of some infants who are otherwise normal is unusually 
large and protrudes slightly from the mouth, but is of normal shape. 
It is pointed, but somewhat thickened in the middle (Fig. 93). As 
the infant grows older this anomaly becomes less apparent. In ex- 
treme cases the tongue protrudes from the mouth as a tumor mass. 
It is discolored — generally of a livid hue — and becomes ulcerated, 
especially at the line of the teeth. Infants thus affected cannot nurse, 
and the tongue must be reduced in size by surgical means. This con- 
genital enlargement of the tongue may be due to an increase either in 
the connective or muscular tissues, or in both. In other cases the 
lymph-spaces of part or the whole of the organ are dilated — there 
is a lymphangioma of the tongue. 

There are thus two forms of macroglossia — the one is called 
macroglossia lymphatica congenita, the other macroglossia congenita 
hypertrophica. The lymphatic form shows for the most part a 
gross hypertrophy of the organ and more rapid growth, combined 
with secondary changes in the lower jaw and teeth. The surface of 
the tongue is changed in appearance through defects of the epithe- 
lium and the results of inflammatory processes. The papillae are 
enlarged, the organ is bluish red, nodular, not changed by mus- 
cular action and can be compressed. Speech is for the most part 
changed. The tongue in the hypertrophic form is smooth, the sur- 



RINGWORM OF THE TONGUE. 



441 



face enlarged, the growth slow, the tongue less movable than nor- 
mally and changed by muscular action. It cannot be compressed, 
as in the lymphatic form, and is less apt to become inflamed. The 
surgical procedures have consisted in compression, excision, and an 



Fig. 93. 



/ 


IpwiPI 


^ 




c 


'".^ 


11 




#^ 


.-• 


} 




jO- 










h 






"^XH^^ 


^ ^ -^ 


■ '■> '■ 


^ 


^>>'; 


-^>, 


- ' 


^ 






N -^ ' 


4/"; 




u^' 





Simple macroglossia. 



ignipuncture, the latter being the most advisable (Eras). In cretins 
and the Mongolian forms of idiocy the tongue is also enlarged. It 
is broad, thick, and flat, and protrudes from between the lips. 



Ringworm of the Tongue. 

( Wandering Rash of the Tongue ; Lingua Geographica.) 

Ringworm of the tongue is a common affection of infants and 
children. It was probably first described by Santulus in 1854. 
Parrot regarded it as a symptom of hereditary syphilis — a view 
which has no clinical support. 

In 103 cases reported by Bohm, the condition occurred sometimes 
in early infancy, sometimes as late as the twelfth year of life, and was 
most frequent between the first and the second year. 

The etiology is obscure. Bohm believes it to be connected with 
a lymphatic diathesis (scrofulosis). It is found chiefly among chil- 
dren of the lower classes. It may, however, be seen in children in 
good hygienic surroundings and who are otherwise healthy. 

If scrapings from the borders of the patches of an affected 
tongue be examined microscopically when fresh, large numbers of 
zooglsea of coccus form, in some cases mingled with sarcinse, will 
be seen. The presence of the latter micro-organism explains the 



442 



DISEASES OF THE DIGESTIVE SYSTEM. 



yellow color of the border of the patches in some cases. The dis- 
ease sometimes affects several children of a family. 

The symptoms are limited to the appearance of the patches on 
the tongue. At the tip, but most frequently at the sides of the 
tongue, are seen areas sharply circumscribed by narrow, sinuous, 
perfectly oval or round borders (Fig. 94). The border is not only 
distinctly raised above the epithelium of the tongue, but also is of 
limited breadth and has a more pronounced whitish or yellow-white 
color than the rest of the tongue. Inside this border, if the patch 
is oval, the tongue seems to be denuded of its epithelium and is 
reddish in color. This condition should be differentiated from des- 
quamation of the epithelium on the dorsum of the tongue, which 
presents a similar appearance, but in which the patches have not 
the band-like border (Fig. 95). Children do not appear to suffer 
inconvenience from this condition of the tongue. 

Treatment of the most diverse kinds, including local application 
of tincture of iodine and the use of ferric chloride, has in my exper- 
ience failed to produce results. 



Fig. 94. 



Fig. 95. 





Ringworm or wandering rash of the 
tongue, lingua geographica. 



Epithelial desquamation of the 
tongue. 



Desquamation of the Epithelium of the Tongue. 

In this condition, which has been confounded with that just 
described, there are seen areas of irregular size and apparently 
denuded of epithelium. The boundary of these areas is sharply out- 
lined, but the epithelium bounding the areas is apparently normal 
(Fig. 95). The tongue looks as if the epithelium had been scraped 
off. The condition demands no treatment, since it is only a symp- 
tom of mild derangement of the digestive processes. 



TONG UE-S WALL WING. 443 

Tongue-swallowing. 

Tongue-swallowing is a term applied to a peculiar phenomenon 
seen in some infants who are the subjects of nasal obstruction. 
Infants normally breathe through the nose when at rest, the tongue 
being in contact with the roof of the mouth. If nasal breathing is 
obstructed either by swelling of the mucous membrane or by de- 
formity of bone, the infant experiences great difficulty in breathing 
through the nose. As a result, not being accustomed to keeping 
the mouth open and the tongue on the floor of the mouth, the inef- 
fectual efforts at nasal and mouth-breathing cause the infant to draw 
the tongue inward. The tip of the organ folds on itself, and may 
be drawn backward into the mouth in the efforts at mouth-breathing, 
causing a peculiar snapping noise to be heard on inspiration. 

Treatment. — The remedy in these cases is nasal douching, and 
dilatation of the nasal passages with pledgets of cotton. The cotton 
is rolled around a probe or applicator, moistened with castor oil, 
introduced once a day into the nares, and allowed to remain about 
five minutes. 

Tongue-tie. 

Tongue-tie is a condition for the relief of which the physician is 
frequently consulted. Some mothers will ascribe inefficient nursing 
to this condition. With a breast secreting sufficient milk tongue-tie 
would not prevent nursing. The existence of the condition is readily 
detected if the organ is bifid at its tip when protruded. The frenu- 
lum will m such cases be seen to extend to the extreme tip of the 
tongue in a fan-shaped manner. 

Treatment. — The frenulum being membranous is easily divided. 
It should be caught in the bifid groove of the pocket-case director 
and made tense, and the membranous portion divided with a pair of 
round-ended scissors. The ends of the scissors should be directed 
to the floor of the mouth. There is little bleeding. The infant 
should be placed at the breast directly after the operation, so that 
the act of suckling may stop the hemorrhage. 

III. MALFORMATIONS OF THE UVULA. 

The uvula is often bifid in infants. This condition is only of 
anatomical interest. There are cases in which the uvula is relaxed 
and elongated. In one case, in a boy five years of age, the uvula 
was so long that it gave rise to an incessant night-cough. On ex- 
cision of the uvula the cough ceased. 



444 



DISEASES OF THE DIGESTIVE SYSTEM. 



IV. DISEASES OF THE (ESOPHAGUS. 

Congenital Anomalies. 

Branchial Fistulae. — Among the congenital anomalies connected 
with the oesophagus is the so-called fistula colli congenita. This is 
due to a faulty closure of the branchial clefts in foetal life. This 
fistula is generally unilateral, and is found at the inner side of the 
sternomastoid muscle. It may be bilateral. It generally leads to 
the pharynx or oesophagus, and may end in a blind canal. The 
canal may discharge mucus containing ciliated epithelium and leuco- 
cytes. Hennes described a cartilaginous growth in the neck, of 
which I have seen an instance. It occurs in the same situation as 
the above fistula, and is traceable to the same faulty closure of the 
branchial clefts. 

Branchial cysts are cystic tumors of the neck and some parts of 
the head, originating from congenital defects of development. The 

Fig 96. 




Congenital branchial cyst. Infant seven months of age (Dr. Henry Heiman's case). 



primary origin of these tumors corresponds to the location of one 
of the branchial clefts, most frequently the second and third, in the 
vicinity of the larynx and pharynx. They are in intimate relation 
with the sheaths of the large vessels of the neck, the jugular vein, 
and carotid artery. The cysts are classified, according to their con- 
tents, into mucous, atheromatous, serous, and hematocysts. Bran- 
chial cysts are of rare occurrence. The serous variety is observed in 



CONGENITAL ANOMALIES OF THE (ESOPHAGUS. 445 

early life, either congenital or develops during infancy or childhood^ 
whereas the atheromatous cysts are seen in early adult life. These 
cysts are seen most frequently on the left side of the neck. Their 
further consideration and treatment is of a surgical nature. 

Diverticula of the (Esophagus. — These occur in childhood, 
are congenital in origin, and are accompanied by symptoms of diffi- 
cult deglutition of solid foods, though fluids may be swallowed. In 
some cases the food collects in the diverticulum, causing swelling 
of the neck, with spells of coughing and consequent emptying of 
the diverticulum. With the difficulty of deglutition there is regur- 
gitation of the food after eating. In a case recorded by Kurz there 
were undulatory movements at the side of the neck and gurgling 
noises heard on swallowing. A sound could be passed into the 
stomach, but at the junction of the upper third with the lower two- 
thirds of the oesophagus the sound passed into a pocket. In this 
case food could be caused to pass into the stomach while the patient 
was placed in a certain position. 

The above diverticulum may be primary, of the congenital 
variety ; or secondary, due either to a stricture of the oesophagus 
and dilatation above the stricture, or to traction from without on 
the oesophagus by a caseous lymph-node. 

Congenital Stricture of the (Esophagus. — Sneider has col- 
lected 15 cases of congenital stricture of the oesophagus, most of 
which gave no symptoms during infancy and childhood. The 
stricture in these cases was either in the form of a ring of tissue or 
folds with thickening of the mucosa. They were present either in 
the upper or lower part of the oesophagus. Only 2 of the 15 cases 
died during childhood, the symptoms appearing for the most part in 
early youth. 

The case recorded by Turner was that of a child eighteen months 
old. It had always suffered from difficulty in swallowing, and 
weighed only 14i pounds. The mother said that since the period 
of weaning the child had become emaciated, and the difficulty in 
swallowing had increased so that finally all food was rejected. A 
sound having the diameter of the small finger could not be intro- 
duced into the stomach. Postmortem, the stenosis was found at the 
cardiac end of the stomach and was of the size of a No. 2 catheter. 

Congenital Atresia or Absence of the (Esophagus. — The 
oesophagus may be entirely wanting, and in such cases other organs 
show anomalies ; or there may be atresia of the middle third of the 
oesophagus ; or the oesophagus may communicate in part with the 
larger bronchi. The stomach may be absent in some of these cases. 
In such cases the infants swallow, choke, have cyanotic attacks, and 
in three or four days cease to live. In one case published by Simon 
the oesophagus ran circularly around the trachea ; the patient sur- 
vived and died in adult life. 



446 DISEASES OF THE DIGESTIVE SYSTEM. 

CEsophagitis. 

Any inflammation of the mouth or the pharynx may extend into 
the oesophagus, such as croup, diphtheria, burns, corrosions, sprue. 
These affections cause no characteristic symptoms apart from the 
primary disease. 

Caustic CEsophagitis. 

{Traumatic Stricture of the (Esophagus.) 

This is caused by the action of caustic alkalies or mineral acids 
on the tissues of the oesophagus, and the intensity of the corrosion 
varies with the amount and strength of the caustic taken internally. 
The caustic alkalies, such as potash and ammonia, are especially 
likely to be swallowed by children. The effects of the corroding 
agent are shown first externally. If a concentrated mineral acid 
has been taken, there is a brown or a black eschar. In less con- 
centration we have white or grayish eschars, and later mild inflam- 
matory reaction. Alkalies cause gelatinous swelling of the mucous 
membranes covering the lips, tongue, and buccal cavity. If the 
alkali be very strong, the tissues are converted into a yellow or 
brownish mass, and the fatal issue sets in before any reaction takes 
place. If the agent be dilute, superficial ulcers form after the pri- 
mary corrosion. Reaction sets in, and, following the inflammatory 
stage of the reaction, cicatricial effects result, such as stricture. 

The symptoms accompanying the swallowing of corrosive poisons 
are pain, which is constant, incessant crying, restlessness, due to a 
burning sensation in the mouth, attended with great pain and difficulty 
in swallowing. In some cases blood and purulent matter are vom- 
ited. There is great thirst. In other cases, where the concentra- 
tion of the alkali has not been great, the lips are swollen, the 
mucous membrane of the mouth presents a whitish, gelatinous, 
swollen appearance. There is constant salivation ; the children 
refuse to take solids or liquids, inasmuch as the least attempt at 
swallowing causes great pain. 

The treatment of these cases is at first medical. Demulcents 
and milk are given in large quantities, and the physician should 
refrain from examinations with instruments lest perforation of the 
oesophagus or stomach result. After a few weeks, the primary 
effects of the corrosion having passed off and cicatrization of the 
ulcers having taken place, a stricture of the oesophagus results. The 
treatment of this stricture is surgical. 

Pericesophageal Abscess. 

( Retro-cpsophageal A bseess. ) 

Griffith has reported 12 cases of this aff'ection. It is not infre- 
quent in infancy and childhood. The oesophagus begins above at 



PERKESOPHAGEAL ABSCESS. 447 

the seventh cervical vertebra, lying in front of the spine. It passes 
behind the right bronchus between the two pleural sacs, behind the 
pericardium, and finally passes through the diaphragm. Any affec- 
tion of the spine, pleura, pericardium, or lymph-nodes at the root 
of the lung may either cause pressure on the oesophagus, involve it 
in inflammation, or, if suppuration exists, the pus may break into 
the lumen of the oesophagus. Cases are recorded in which the 
pressure of an intubation tube or diphtheria of the pharynx has 
involved the perioesophageal tissue and caused abscess ; or a foreign 
body in the oesophagus may cause perforation and ulcer, involving 
the adjacent connective tissue. If a foreign body is lodged in the 
oesophagus and is contaminated, as in the case of Soltmann, with 
actinomycosis, abscess of the oesophagus and lung may result, with 
actinomycosis of the latter organ. The most frequent cause, how- 
ever, of peri- or retro-oesophageal abscess is disease of the vertebrae 
of a tuberculous nature. 

Symptoms. — These will vary with the cause. An abscess of 
the pleura or a lymph-node pressing on the oesophagus will give 
symptoms of oesophageal stenosis. In some cases the pressure may 
interfere not only with deglutition but with respiration, and give 
rise to symptoms resembling laryngeal stenosis, necessitating intu- 
bation. As soon as the tube, however, is withdrawn from the 
larynx, the dyspnoea returns. The larynx may also be pushed to 
one side. There may be temperature, due to the primary disease. 
In one of my own cases there were spasmodic attacks of coughing, 
accompanied by cyanosis, and in one of the attacks a discharge of 
pus. The source of the pus in this case was probably an empyema 
which had opened into the oesophagus. These attacks were repeated 
at intervals, though with less expectoration of pus. The child 
finally made a good recovery. 

In spondylitis there will be symptoms of disease of the vertebrae. 
If perforation occur from a bronchus or caseous gland, there are 
attacks of coughing, vomiting of food and pus, and finally symp- 
toms resembling putrid bronchitis, and in some cases lung gan- 
grene. 

Diagnosis. — In some cases the diagnosis is not only difficult, but 
impossible. If the cause is evident and the abscess can be reached 
wdth the finger, the diagnosis can be made ; but if the abscess 
is deep-seated, beyond the reach of exploring instruments, the dis- 
ease is diagnosed only at the autopsy table. If the swallowing 
of a foreign body has preceded symptoms which resemble retro- 
oesophageal abscess, an x-raj should be taken to locate the body. 

The prognosis in deep-seated retro-oesophageal abscess is bad; 
that in spondylitis likewise. The spontaneous rupture of the abscess, 
with discharge of pus externally and recovery, is exceptionaL The 



448 DISEASES OF THE DIGESTIVE SYSTEM. 

spontaneous rupture of a retro-oesophageal abscess may result in pus 
finding its way into the larynx^ thereby causing suffocation. 

The treatment of retro-oesophageal abscess, if diagnosed 
promptly, is surgical. It may be stated, however, that these 
abscesses are best opened from without, and we sliould hesitate to 
make an internal incision in a deep-seated retro-oesophageal abscess. 

Keferences of Authoeities for Collateral Blading. 

Babes and Zambolovici : Annales d'Instit. de Path., etc., Bucarest. 
Bernheim : Centralbl. f. Bakt., 1898. 
Bishop and By an : Jour. Amer. Med. Assoc., 1902. 

Blackader : '' Ketropharyngeal Abscess," Montreal Med. Jour., 1888-1889, vol. 
xvii. 

Bokai, L, Jr. : Paediatrische Arbeiten Henoch, 1890. 

Crozer Griffith : " Eetro-cesophageal Abscess," Trans. Amer. Pediat. Soc, 190L 

Epstein : " A Pseudodiphtherie," Jahrb. f. Kinderheilk., Bd. xxxix, 

Forcheimer : Archives of Pediatrics, 1892. 

Freymxith and Petruschky : Deutsch. med. Wochenschr., 1898, No. 38. 

Friihwald: Jahrb. f. Kinderheilk., Bd. xxix. p. 200. 

Nidot and Marotte: Eev. de Medecine, 1901. (Vincent's bacillus.) 

Bosinsky: Zeitschr. f. Geb. u. Gyn., Bd. xii. 

Walsh: "Noma," Jour. Amer. Med. Assoc, 1902. 

Sobel and Herrman : N. Y. Med. Jour., 1901. 

Vincent: Annal, de I'lnstit. Pasteur, 1896. 

Woronichin : Jahrb. f. Kinderheilk., Bd. xxvii. 



V. DISEASES OF THE STOMACH AND INTESTINES. 

Classification. — The classification of the diseases of the gastro- 
enteric tract occurring in infancy and childhood must necessarily 
be schematic for the present^ for much is yet to be learned, from 
chemical, physiological, and pathological standpoints, concerning 
some of these affections. Any classification, therefore, must be 
founded on a mixed etiological basis, and must, of necessity, be 
subject to future revision. For the present we may divide these 
diseases into : 

First. Those which are caused by some congenital defect. 

Second. Those which are purely functional, in which no ana- 
tomical lesion is supposed to be present, and in which, the cause 
being removed, the organ returns to its normal condition, no lesion 
remaining. Such are the acute dyspejDsias of infancy and childhood, 
both stomach and intestinal ; the various forms of vomiting, con- 
ditions of colic, and tympanites. 

Third. A series of disturbances caused, it is supposed, not only 
by bacteria, but by their toxins, such as acute gastro-enteritis, sum- 
mer diarrhoea, cholera infantum. In these diseases the anatomical 
lesion, if any exists, is in the majority of cases only temporary, for 
the patients recover. In the fatal cases the anatomical lesions are 
very slight and disproportionate to the severity of the disease, 



THE STOMACH. 449 

being due, it is at present supposed, to the direct action of the bac- 
teria and their toxins on the superficial structures of the stomach 
and gut. 

Fourth. Those diseases which are due to the direct action of the 
bacteria themselves, which, in addition to causing constitutional 
symptoms, due to the passage of the toxins into the circulation, also 
cause serious anatomical changes in the tissues of the gut, some of 
these changes causing eventually the death of the patient. In this 
class we would place dysentery of infancy and childhood, and the 
various forms of ileocolitis, which have, as yet, no firm etiological 
basis established by investigation and experiment. 

Fifth. A series of diseases caused by some anatomical condition 
or neurosis. In this class must be placed the forms of congenital 
stenosis of the pylorus, dilatation of the stomach, which, though 
primarily caused by dyspeptic disturbances, eventually supervenes 
as the result of anatomical weakness of the muscular structures of 
the stomach. In this class we would place the various forms of 
constipation depending upon congenital dilatation of the colon. 

THE STOMACH. 

Anatomy. — The oesophagus enters the diaphragm at about the 
level of the ninth dorsal vertebra ; the cardia is on a level with the 
tenth dorsal vertebra ; the pylorus is in the majority of cases situated 
in the median line, but in some cases is slightly to the right of it. 
It is midway between the tip of theziphoid cartilage and the umbili- 
cus, and, being behind the liver, is not palpable. The stomach lies 
in an oblique position, passing from behind forward and downward. 
The pylorus is from two to two and one-half bodies of a vertebra 
lower than the cardia. In the newborn infant the inferior portion 
of the stomach has a fundus form (Pfaundler), which later becomes 
more marked. Occasionally there is no fundus, and ihQ stomach is 
then of cylindrical shape. Between the time of birth and the seventh 
month the fundus of the stomach increases to fully twice its original 
length (Pfaundler). 

The capacity of the stomach is still a matter of speculation. The 
absolute capacity, as given by Fleischman, Drewitz, Pfaundler, 
Holt, and Rotch, varies with the method employed to determine it. 
The work thus far done has been carried out on the cadaver, and, 
moreover, the methods employed presuppose an amount of pressure 
(14 c.c. to 30 c.c.) of water which does not exist in the normal 
state during life. The stomach contracts after death (systole) ; the 
distention with air or fluids is thus partly artificial. Lastly, the 
stomach capacity is of little aid in determining the point at issue 
— the quantity of food which should be taken by a healthy infant 
at each feeding. Figures giving absolute stomach capacity are use- 

29 



450 DISEASES OF THE DIGESTIVE SYSTEM. 

ful only as indicating the actual size of the organ when full of fluid, 
a condition rarely present during life. 

In the following table Pfaundler's results are compared with those 
of others. They were obtained by postmortem distention with fluid 
at a pressure of 30 c.c. of water. Fleischman distended the stom- 
ach at 14 c.c. of water pressure. 

Fleisch- Drewitz. Pfaund- Rotch. Holt. 

MAN LER. 

C.C. c.c. cc. c.c. c.c. 

At birth 30 . . 30 30 36 

One week . 45 

One month 77 99 150 75 60 

Two months 79 115 175 96 99 

Three months 140 130 200 100 135 

Four months 165 230 107 150 

Five months 290 253 260 108 170 

Six months 260 297 295 . . 264 

Seven months 217 330 

Eight months . . 289 365 

Nine months 510 406 

Ten months 375 350 445 

Eleven months 535 485 . . 243 

Twelve months 500 515 

One to two years 220 588 640 

Function and Motility. — The stomach of breast-fed infants 
empties itself in two hours after the ingestion of a full nursing. If 
the quantity of milk taken is small, a shorter time suffices. Bottle- 
fed infants taking cows' milk need fully three hours to accomplish 
the same result. This fact alone teaches that intervals of rest be- 
tween the nursings, and a rest of four or five hours once in twenty- 
four hours, are necessary. 

Marking out the Stomach by Percussion. — This procedure is 
difficult with infants and children. The normal stomach is rarely 
found outside of the left hypochondrium. The liver fully covers 
the stomach in the collapsed state. In the recumbent posture 
the stomach may be mapped out on the anterior abdominal parietes. 
It comes forward in the triangle formed on one side by the bor- 
der of the left lobe of the liver and on the other by the border 
of the ribs. Above, the apex of the triangle is formecf by a 
junction of the ribs and left lobe of the liver. Below, the base of 
the triangle is of variable length. In the axillary line the fundus 
in a moderately distended state is in contact with the thoracic walls, 
between the liver above and the spleen below. Above, it is sepa- 
rated from the lung resonance by a strip of dulness (the left lobe of 
the liver) which changes position with the movements of the dia- 
phragm. The tympanitic resonance reaches downward in a vertical 
direction from the sixth to the eighth rib. Behind this, tympany is 
limited by the posterior axillary line ; in front, by the triangle above 
referred to, I have frequently been able to confirm these statements 



THE STOMACH. 451 

of Fleischman. Anteriorly, I have with the aid of a gastrodia- 
phane shown that the transverse colon passes in front of the stomach 
just beneath the liver. It should be remembered that tympanitic 
resonance in the epigastrium is not always due to the stomach. 

Acids of the Stomach. — When digestion is not in progress the 
stomach contains a tenacious, colorless mucus^ neutral in reaction. 
When food is in the stomach, the reaction is acid. 

Hydrochloric acid is normally present in the stomach of the in- 
fant (Leo, Van Puteren, Wohlman) ; lactic acid only occasionally. 
Heubner found O.IG to 0.2 pro mille of lactic acid present. A 
considerable amount of hydrochloric acid unites with the salts and 
albumin of the milk, and is found as combined hydrochloric acid. 
When combination is no longer possible, the residue appears as 
free hydrochloric acid. The amount of free hydrochloric acid 
depends on the quantity of milk ingested, and varies from 
0.8 to 2.1 pro mille. I have frequently failed to find it in the 
stomach contents of infants who are fed irregularly at frequent 
intervals. In healthy breast-fed infants free hydrochloric acid is 
found in from one and a quarter to two hours, and in bottle-fed in- 
fants in from two to two and a half hours after nursing. The effect 
of the lab-enzyme on the milk is marked in breast-fed as compared 
with that in bottle-fed infants. In the former the action of the acid 
delays that of the lab-ferment, while in the latter coagulation of the 
casein occurs in a short time and in large flocculi. The diflPerence 
in retarding the action of the lab-ferment is due to the increased 
alkalescence of mother's milk, which requires more acid to neutralize 
the alkali, and thus to render coagulation possible : hence the greater 
digestibility of mother's milk. 

Gastric contents containing free hydrochloric acid are antiseptic, 
while combined hydrochloric acid has no such properties. 

Stomach digestion in the infant divides itself into three periods : 
The first, in which the milk is split by the lab-ferment into casein 
coagulum and soluble albumin ; the second, in which the stomach 
contents become acid, having been previously neutral or alkaline, 
and in which chlorine combinations are entered into by the casein 
and lactic acid is formed ; and third, in which the above phase 
of stomach digestion is completed, the contents pass into the gut and 
free hydrochloric acid appears. 

Digestion is thus accomplished by a soluble ferment, so-called 
lab-ferment or pexin, which coagulates the casein of the milk ; a 
soluble ferment, pepsin, which partly dissolves and peptonizes this 
coagulum ; and chlorine combinations (HCl), which unite with the 
partially peptonized casein, and toward the end of digestion produce 
free hydrochloric acid. Thus the principal changes in the milk, so 
far as the stomach is concerned, occur in connection with the casein. 



452 DISEASES OF THE DIGESTIVE SYSTEM. 

As soon as the milk enters the stoQiach, it is coagulated by the lab- 
ferment, whether its reaction is neutral, alkaline, or acid. This 
casein coagulation depends upon the lab and not upon the acid reac- 
tion of the stomach juice. Lab-ferment is present in the infant's 
stomach as such, and can be demonstrated in the stomach of pre- 
mature and sick infants. Lab-coagulation of the casein is accom- 
plished, according to Duclaux, in about fifteen minutes. Part of the 
casein coagulum is acted on by the pepsin and chlorine combina- 
tions and is converted into absorbable peptones (casease or caseon), 
the remainder passes into the intestine, where digestion is com- 
pleted by the pancreatic ferments. 

The casein coagulum of cows' and of human-breast milk are essen- 
tially different, the former being a firm mass, containing in its meshes 
the fat of the milk ; the latter being in fine flocculi with little of 
the fat of the milk, and easily acted on by the stomach juices. In 
the bottle-fed infant the stomach, half an hour after feeding, still 
contains large coagula, whereas at this time the breast-fed infant's 
stomach contents consist of an easily absorbable homogeneous mass. 
Liquefaction is the work of the pepsin, which is present in the 
stomach juices of the newborn infant, though throughout infancy its 
action is weak and only sufficient to act on the proteids of the milk. 
Thus, half an hour after feeding, albumoses and peptones are found 
in the stomach both of breast-fed and bottle-fed infants. 

Milk sugar is split partly into lactic acid about fifteen minutes 
after feeding, and by the action of lactase (Marfan) into glycose and 
galactose. This view, however, is not accepted by all observers, 
lactic acid not being admitted as normal to the stomach. The salts 
of the milk which have not been precipitated are directly absorbed. 
The fats enter, with the casein coagula, into the gut almost 
entirely unchanged, or a fractional part is saponified by lipase (Mar- 
fan) and absorbed in the stomach. 

In general, it may be stated that in breast-fed infants digestion 
is completed in one and one-half to two hours : in artificially fed 
infants taking boiled milk in two and one-half to three hours, and 
in four hours in those taking raw milk. 

The bacterial flora of the infant stomach are as yet not fully inves- 
tigated. So far as known the stomach may contain the Bacterium 
coli commune, the Bacterium lactis aerogenes, the Bacillus subtilis 
and the related species, Tyrothrix granulatus and Bacillus butyricus 
of Hueppe, the Bacillus pyocyaneus, the Bacterium lactis erythro- 
genes, the Bacillus megatherium, the Spirillum rugula, a leptothrix, 
Staphylococcus pyogenes, Sarcina ventriculi, oidium, hay bacillus, 
and mould fungi. 

Intestinal Digestion. — The stomach content of the infant as it 
is passed into the intestine consists of unabsorbed water ; proteids 
which are made up of casein coagula and in part of syntonin ; albu- 



THE STOMACH. 453 

moses and peptones in combination with chlorides and ammonia ; 
the fatty acids, leucin, tyrosin ; and finally gases, especially carbon 
dioxide. There are present also the unabsorbed portion of milk- 
sugar and a small quantity of lactic acid. The fats pass into the 
intestine for the most part, suspended in the watery elements of the 
milk or entrapped in the meshes of the casein coagula. The whole 
stomach content has, as it passes into the intestine, an acid reaction, 
more marked in the case of the artificially fed as compared with that 
of the breast-fed infant. 

The intestinal secretions concerned in the digestion of the above 
stomach content are those of the pancreas, liver, and intestinal wall 
(follicles of Lieberkiihn and Brunner's glands). 

Pancreas. — This organ is developed at birth, has a Aveight of 32 
grammes or 1 ounce, and is, therefore, compared with the body- 
weight, much larger than' in the adult. Whereas in the infant the 
pancreas weighs y^^- of the body-weight, in the adult it is g^ J-q-. 

Ferments. — In the adult pancreatic juice there are three fer- 
ments — trypsin, ptyalin, and a fat-emulsifying ferment, steapsin. 
The infant's pancreatic secretion reveals trypsin and steapsin at 
birth, and even in the foetal state. These ferments are present in 
small, but for the infant's uses sufficient, amounts. There is still 
a difference of opinion as to whether ptyalin is present at all in the 
pancreatic juice of the newborn. According to Karowin, a sac- 
charifying power can be detected in the pancreatic juice not earlier 
than the sixth month of infancy, whereas Moro has found traces of 
such a ferment in the pancreas at birtli. The fact of its absence 
or presence in but small quantity at birth has been brought forward 
as an argument against the use of amylacea in the food of the 
artificially fed infant at this age. 

Liver. — The formation of bile begins at the third month of 
foetal life, and at birth both bile and glycogen are found to be 
formed by the liver. The bile, which in quantity is comparatively 
greater at birth than in the adult, contains cholesterin, fiits, lecithin, 
mineral salts, excepting iron. It contains small quantities of tauro- 
cholic acid, and but little or no glycocholic acid. It is not stronglv 
antifermentative at this time. It contains bilirubin and biliverdin, 
and in the young infant urea. Its function in digestion seems to be 
limited to aiding emulsification of the fats. 

The intestinal juices secreted by the follicles of Lieberkiihn 
and the glands of Brunner are alkaline in reaction, and in the foetus 
and newborn the ferments, present in these juices in the adult, seem 
to be absent (Miura). The role played by these juices in digestion 
is still a subject for study. 

The principal process taking place in intestinal digestion of the 
infant is the transformation of the casein of the milk by the trypsin 
of the pancreatic juice into peptone and hemipeptone. Part of the 



454 DISEASES OF THE DIGESTIVE SYSTEM. 

casein is rapidly changed into peptone by the pancreatic juice, 
whereas the other portion is acted upon at great length, and from 
heniipeptone changed into absorbable substances which, partly crys- 
talline, are taken up by the mucous membrane of the gut and syn- 
thetically transformed into albumins. 

In the breast-fed infant the casein flocculi, being very small, are 
easily digested and dissolved in the duodenum, and the contents of 
this portion of the gut are slightly acid. In bottle-fed infants the 
digestion and solution of the casein is less complete in the duodenum 
than in the breast-fed infant, and the reaction of the contents of this 
portion of the intestine is distinctly acid. 

The milk-sugar is split in the gut into galactase and dextrose and 
thus absorbed. This is accomplished, according to Marfan, by the 
lactase of the intestinal juices. 

The fats of the milk pass from the stomach into the duodenum 
but little changed. They are suspended in the watery element of 
the milk or entrapped in the meshes of the casein flocculi or coagula. 
The fats are partly emulsified and in part split up by the pancreatic 
juice into fatty acids and glycerin, and in these forms absorbed by 
the intestinal villi. The digestion and absorption of the fats, how- 
ever, is incomplete in the intestine of the infant, and much of it is 
excreted in the faeces in the form of neutral fats and fatty acids. 

In the healthy breast-fed infant most of the above digestive 
transformation is completed in the duodenum, and the products are 
absorbed in the upper part of the small intestine. This is especially 
true of the casein or proteids, of which only traces are found in the 
lower portion of the small intestine. 

Intestinal Residue. — After the absorption of the nutritive portion 
of the intestinal mess, the contents of the intestine consist of biliary 
remains, amido-acids, various products of bacterial fermentation, 
acids, and soaps, which are in part taken up and transformed by 
the liver and in part excreted. In addition, there are neutral fats 
and fatty acids. The minute quantity of proteids which has escaped 
digestion and solution and has not been absorbed is transformed by 
the bacterial flora of the gut into the products of decomposition, 
and as such are found as indol, skatol, phenols, and ammonia in 
the faeces. These also are in part taken up by the liver and in part 
excreted. The processes of decomposition, which are quite limited 
in the breast-fed and marked in the artificially fed infant, reach 
their highest development in the colon. 

Characteristics of the Stools of Normal Infants. 

It may be stated that the movements of bottle-fed differ from 
those of breast-fed infants in that they are lighter in color and in 
the main more bulky. In the perfectly normal breast-fed infant 



CHARACTERISTICS OF THE STOOLS OF NORMAL INFANTS. 455 

the stools may at times vary in color and general consistence ; thus 
we can scarcely speak of a uniformly norma] movement. Gregor 
has accounted for this by assuming that the stool of the infant at 
the breast may vary because of the composition of the breast milk 
from day to day and at different hours of the day. Inasmuch as the 
percentage of fat in breast milk varies so widely, the appearance of 
the stool will vary likewise. Infants fed on cows' milk and carbo- 
hydrates will have movements resembling those of breast-fed infants. 
If a number of normal infants are observed, it will be seen that from 
time to time even the breast-fed infant will present movements the 
consistence of which is more or less watery, and which contain 
coarse white curds and particles without any disturbance of the 
functions of the gut. Moreover, if we could receive the movements 
of a normal child on gutta-percha paper, it would be seen that the 
amount of water contained in a normal movement is very much 
more evident than would appear from its ordinary putty-like con- 
sistence on the diaper (Czerny). Infants taking a malted food will 
present movements that are dry and broken up into crumbs, and 
which have a distinct odor of malt. The movement of breast-fed 
babies and those fed upon carbohydrates and fatty food are softer 
than those of babies fed upon cows' milk exclusively. The move- 
ments of infants fed on cows' milk exclusively are lighter in color 
than those of the breast-fed child. The movements of the breast- 
fed infant have a distinctly acid odor, while those of the bottle-fed 
infant have an odor of decomposition. 

In general the fasces of infants may be said to contain digested 
absorbable substances, indigestible substances, digested products of 
digestion and decomposition, anatomical elements of the digestive 
organs of the stomach and gut, mucus elements, and bacteria. If 
the movements of the breast-fed infants are closely examined, they 
are found to contain small whitish curd particles, the milk granules 
of Uffelmann. These were at first thought to be composed of 
casein : it is now known that they are made up of fat-crystals, and 
zoogloea of bacteria. In addition, there are found in the fseces of 
infants epithelial elements, bilirubin crystals, and cholesterin plates. 
Fat appears in the faeces of infants rarely as fat crystals, but gener- 
ally as fatty acids, neutral fats, and soaps. 

The movements of infants fed on a mixed diet contain free starch- 
granules, cellulose, and also cholesterin plates and bilirubin ; the 
products of decomposition — indol, skatol, and phenol — are also 
found, according to the time which has elapsed since the voidance 
of the movements (Blauberg). Sugar is not found in the fseces of 
infants, or only in small quantities (UfPelmann and Blauberg). 
Michael has found that the gross weight of faeces in the newborn 
breast-fed infant was about 1.5 per cent of the gross amount of food 
ingested ; while later in infancy the movements were 2.7 per cent. 



456 DISEASES OF THE DIGESTIVE SYSTEM. ' 

of the amount of food ingested. Rubner and Heubner found that 
in bottle-fed infants the faeces were about 4.7 per cent, of the amount 
of food ingested. Michael found that the faeces in the first days of 
infant life contained about 72 per cent, of water, while in the ninth 
month of infancy they contained 85 per cent. 

Reaction of the Stools. — The reaction of the stools of infants, 
both breast- and bottle-fed, has been the subject of much discussion, 
because of the difference of opinion among investigators as to what 
constitutes a normal movement in an infant. It may be stated, 
however, that the stool of the breast-fed infant is regularly acid in 
reaction and has an acid odor even after being passed for some 
time. The infant fed upon cows' milk has a stool which is alka- 
line in reaction, sometimes neutral, and, under certain conditions 
which no longer may be looked upon as absolutely normal, slightly 
acid. The stools of these infants have an odor more or less recall- 
ing that of stale cheese ; in other words, an odor of decomposition. 

The Daily Number of Movements. — The normal infant, whether 
on the breast or the bottle, will have one, two, or even three move- 
ments daily when in perfect health. In the breast-fed infants these 
movements may be small or large and even contain quite an amount 
of fluid and still be within the limits of health. In the bottle-fed 
infants, however, the stools are, as a rule, larger in bulk than those 
of the breast-fed infants, and contain less water. I have seen bottle- 
fed infants in perfect health who have had as many as four move- 
ments daily, all having normal characteristics. Infants may have 
six movements daily and still be in perfect health. If the consist- 
ence and color are within normal limits, the number simply indicates 
the amount of intestinal residue, and not disease. 

Bacterial Flora of the Intestine. — Two or three days after 
birth the meconium changes its characteristics and assumes those 
of milk fseces. In the milk faeces of the infant nursed at the 
breast we find as predominant, first, a bacillus described by Tissier, 
which stains w^ith Gram's stain, and which in the crude specimen 
seems to occupy most of the microscopic field. This is called the 
Bacillus bifidus communis. It is an anaerobe. In addition to this 
bacillus, we find next in numbers the so-called Bacillus acidophilus 
of Moro and Finkelstein. The latter also stains with the Gram 
stain. In addition to these two bacilli, which are foimd in greatest 
numbers in the faeces of the breast-fed infant, we have a few coli 
bacilli, and also some numbers of the Bacillus lactis aerogenes. 

The faeces of the infant fed on cows' milk present a much more 
luxuriant flora of bacteria than those of the breast-fed infant. There 
are : (1) the Bacillus coli communis, (2) the Bacillus acidophilus in 
small numbers, (3) other Gram-staining bacilli, (4) the Micrococcus 
ovalis (Escherich and Tissier), (5) the enterococcus of Thiercelin, 
(6) a diplococcus staining with Gram, (7) streptococci and staphylo- 



ACUTE GASTRIC DYSPEPSIA. 457 

cocci, (8) Sarcina minuta, (9) the Bacillus lactis aerogenes. The 
Bacillus lactis aerogenes splits milk-sugar into lactic acid, carbonic 
acid, and water, and causes the intestinal cc: tents to become acid. 
In the lower part of the gut we find the Bacillus coli communis, a 
micro-organism which may exist in the presence of any reaction, 
and which splits milk-sugar into lactic acid, carbonic acid, and 
water, and partly splits fat into fatty acids. It is the prevalent 
micro-organism in the stools, though with it we have a number of 
the Bacillus lactis aerogenes, a yellow fluorescent or fluidifying 
bacillus, three fluidifying cocci, a Micrococcus oval is, a porcelain 
coccus, the tetrad coccus, the white and red hay bacillus, a capsule 
bacillus, the Monilia Candida, all of which exist in varying quan- 
tities. 

Acute Gastric Dyspepsia. 

{Indigestion.) 

Acute gastric dyspepsia may clinically be divided into two forms, 
that affecting infants, and that affecting older children. The period 
of infancy is one of frequent disturbances. Mental excitement on 
the part of the nurse may cause the milk to disagree with a breast- 
fed infant. The ingestion of an undue quantity of breast-milk, 
even if of good quality, may cause indigestion. Certain articles 
of food, notably asparagus, if partaken of by the mother, may cause 
gastric irritation. Nursing a breast in which the milk has caked 
will also cause indigestion. 

Symptoms. — ^Vomiting is the first evidence of disturbance of 
the digestive processes in the infant. It occurs after feeding, and 
is at first not accompained by constitutional symptoms or diarrhoea. 
If the exciting cause continues, a slight febrile movement is noted, 
and also slight prostration. The infant is restless, but having vom- 
ited is relieved, and if permitted will again take the breast, the vom- 
iting taking place after each nursing. The bowel movements then 
become disturbed. They may not only be green, but also frequent 
and in some cases fluid. There are in all cases colic and tympanites. 

Acute gastric dyspepsia in older children may be caused by some 
article of diet which has disagreed with the patient. The symptoms 
are much the same as those seen later in life. It is important both 
with infants and children to determine whether the symptoms are 
due to improper food or whether proper food has for some reason 
disagreed. Bottle-fed infants are liable to indigestion if the milk 
contains any extraneous substances, not necessarily toxic ones. 

A baby may have thrived for weeks on a certain food-mixture, 
when suddenly, without apparent cause, symptoms of gastric dys- 
pepsia supervene. In such cases it will be found that the acidity of 
the milk was greater than usual, or that the fodder of the cows fur- 
nishing the milk has been changed. 



458 DISEASES OF THE DIGESTIVE SYSTEM. 

Course. — If the food is suspended and proper treatment in- 
stituted, the symptoms subside and the infant recovers, but if the 
exciting cause is not removed, more serious disturbance of the stomach 
and gut will develop. 

Treatment. — It is best both with breast-fed and bottle-fed infants 
to discontinue the giving of all food as soon as symptoms of indi- 
gestion appear. With the suspension of food the administration of 
a simple cathartic (castor oil) is all that is necessary. The infant is 
put for twelve hours on a solution of white of egg, and the breast 
pumped regularly every three hours to prevent caking. The breast 
may then cautiously be exhibited. Stomach washing should not be 
resorted to, and the breast should not be denied for too long a period. 
If, on resuming breast-feeding, symptoms reappear, an analysis of 
the milk should be made. Its composition may have changed and 
too much fat may be present. We should not be hasty in taking an 
infant from the breast and placing it on the bottle on account of a 
few^ symptoms of gastric dyspepsia. Proper regulation of the diet 
and the taking of proper exercise by the nurse will frequently cause 
the desired adjustment of the constituents of the milk and the dis- 
appearance of symptoms. 

Habitual Vomiting of Infants. 

Habitual vomiting of infants refers to the regurgitation of 
milk in the uncoagulated state shortly after nursing. It occurs in 
infants in apparently good health, and is not followed by loss of 
weight or disturbance in the functions of the gut. Some infants 
vomit curdled milk in the same manner. The cause of this form 
of vomiting has been variously explained. The simplest explanation 
is, that by slight pressure the food is forced into the oesophagus and 
thence reaches the mouth. It is a well-known fact that the stomach 
of the infant can be emptied by gentle abdominal pressure. Another 
explanation is that on deep inspiration the negative pressure caused 
by descent of the diaphragm forces a certain amount of fluid from 
the stomach, which is almost vertical in the infant, into the oesophagus 
and thence into the mouth. This form of vomiting requires no 
treatment. The general impression is that it can be stopped by 
regulating the amount of breast-feeding, but this belief is erroneous, 
as the vomiting persists after such precautions have been adopted. 
Fleischman thinks that the habit is hereditary in certain families. 

Cyclic Vomiting. 

( Periodic vomiting ; Recurrent vomiting. ) 

Definition. — Cyclic vomiting is a condition in which there appear 
at intervals more or less remote from each other attacks of vomiting, 
accompanied by marked prostration without rise of temperature, in 



CYCLIC VOMITING. 459 

which there is an absolute intolerance of the stomach for even fluid 
food. This condition has been described under various headings 
both in France, 1841, by Dr. Gruere ; by Lombare, in 1861; in 
England by Gee, and in America by Rotch, Holt, Rachford, Edsall, 
Koplik, and others. 

The etiology of this condition is obscure, and it is most proba- 
ble that the theory of Rachford is correct — that the symptom- 
complex is one of gastro-intestinal lithsemia, due to an increased 
acidity of the fluids of the body as the result of disturbed meta- 
bolism. In one of these cases Herter has analyzed the amount 
of uric acid in the periods preceding, during, and following the 
attack. In such an analysis the gross amount of uric acid was 
greatest on the second day of the disease, and fell rapidly on the 
third day to near the normal. The normal relation of uric acid to 
urea in these patients was as 1 : 54. During the attack the relation 
of uric acid to urea, as a rule, was 1 : 85, and in the normal condi- 
tion it fell to 1 : 42. Griflith considers the condition a species of 
toxaemia. 

It seems to me, from a study of a number of ray own cases, that 
the condition described by Rachford must obtain ; in addition, how- 
ever, these are crises in which the patients seem to sufler distinctly 
from attacks of intestinal intoxication, inasmuch as treatment 
directed toward placing the conditions in the gut on a normal basis 
seems to benefit them materially. In most of my own cases there 
has been a history of constipation extending over long periods of 
time, and an intolerance of milk as the main article of diet in other 
cases. 

Other authors (Holt) have not found constipation to be a promi- 
nent factor in their cases, but rather that the ingestion of certain 
forms of foods, such as amylacea, are apt to precipitate an attack. 
In only one of my cases have I found that amylacea were badly 
borne, and the ingestion in this case of a cereal gruel seemed to pre- 
cipitate an attack ; constipation, however, existed in this case from 
infancy. 

The symptoms in these cases are quite characteristic ; the subjects 
of this form of disturbance may be well developed, but, as a rule, 
they are pale. In some of them the ansemia is quite marked, and 
the children have a pasty complexion. The attack is preceded by a 
period during which the child complains of slight pain in the stom- 
ach ; in some cases this may be absent. The child aw^akens in the 
morning, feels tired, has no appetite for breakfast, and has pro- 
nounced pallor. Vomiting sets in ; the food is first rejected and 
then vomiting persists ; in some cases even blood with mucus is 
vomited from the stomach. In other cases the contents of the 
duodenum may appear in the vomitus in the form of biliary matter. 
The child finds most comfort in lying quietly on its back, refusing 



460 DISEASES OF THE DIGESTIVE SYSTEM. 

to take any food ; even water is vomited. There is no temperature ; 
there may be a slight increase of the pulse-rate, and it may have a 
bounding character, and the heart-impulse may be increased in 
force. There may be a complaint of epigastric pain. The prostra- 
tion in some cases is extreme ; the condition may last twenty-four 
hours to two or three days, until normal conditions are established. 
The vomiting may recur several times in twenty -four hours ; it 
gradually diminishes in frequency and disappears. During this time 
there is no movement from the bowels, or there may be a consti- 
pated movement as the result of enemata, with the voidance of a 
large quantity of mucus. The following is a characteristic case : 

Dorothy E., five years of age, fed in infancy on modified milk ; 
has never suffered from any disease of greater severity than a 
grippal attack. She has been constipated since infancy, and this con- 
stipation has lately become more marked. After having been put 
on raw milk and cream, the constipation abated for a few weeks and 
then returned. The constipation was only relieved by the constant 
use of cathartics, and sometimes these were not effective. The child 
is a well-developed girl, thirty-five pounds in weight, with a body- 
length of 102 cm. (3 feet 4 inches) ; the abdomen is protuberant; 
there is no disease of the heart or lungs ; the liver and spleen are 
normal in size. The urine does not contain albumin or casts. The 
child is anaemic, has a tired expression, and in her movements there 
is considerable mucus. Her vomiting attacks began when she was 
four years of age. These attacks last two or three days, during 
which the child rejects all food. The attacks begin very much in 
the manner just described. In one of these attacks the vomiting 
was so severe that there was an alarming hemorrhage from the 
stomach. The odor of the breath in the first day of the attack is 
" sweetish '' (acetone). 

Some of my cases during the attacks presented albumin and a 
few hyaline casts in the urine. These disappeared after subsidence 
of the attack. Acetone bodies may be present in the urine in 
increased quantity. 

Diagnosis. — The practitioner should be exceedingly cautious when 
presented with a case of vomiting in a child from four to five years 
of age not to hastily conclude that it is one of cyclic vomiting before 
making a thorough examination, not only of the urine, but of the 
other viscera. 

A case has recently come under my notice, observed for four 
years, in which a diagnosis was made of cyclic vomiting, but which 
is one distinctly of nephritis with recurrent attacks of uraemia. 

Some authors, such as Rotch, have laid stress on the fact that 
these attacks may also simulate meningitis. 

Course and Prognosis. — The prognosis in this condition, so far 
as life is concerned, is good. There are some cases recorded which 



CYCLIC VOMITING. 461 

have terminated fatally. The author has not met in his experience 
such an unfortunate occurrence. The course of the disease, if prop- 
erly handled, ends in recovery in from twenty-four hours to three or 
four days. 

The treatment of cyclic vomiting is divided into the treatment 
of the attack and the intervals between the attacks. 

Treatment of the Attack. — The patient is put to bed, kept per- 
fectly quiet, and little or no fluid is given by the stomach — certainly 
no solid food. The stomach is quieted with small doses of codeia. 
This is the only remedy which in my hands seems to have had any 
influence in controlling prolonged vomiting. Enemata consisting of 
saline solution are given twice daily. They should be high enemata, 
and at least a quart of water should be thrown into the rectum at 
each sitting. In the intervals between the enemata the child should 
be nourished by the rectum. Somatose solution — ^^1 drachm of soma- 
tose to 8 ounces of cold water — is heated to a lukewarm tempera- 
ture, and given by the rectum in quantities varying from 2 to 4 
ounces every three hours. The patient is given small pieces of ice 
to swallow, in the case of older children. No other treatment is 
necessary until the attacks of vomiting subside of their own accord 
within twenty-four hours. It is surprising to see how comfortable 
these little patients will be if little or no fluid is taken by the mouth ; 
in fact, some of them are intelligent enough to find this out for 
themselves and refuse all nourishment. On the second day of the 
disease, when the vomiting has subsided to a great extent, we may 
give the patient broths, fruit juices, diluted gruels ; and on the third 
day we may gradually return, if the stomach is tolerant, to a semi- 
solid diet, and finally to a full diet. As soon as the stomach is 
tolerant of fluids, and even at the height of the attack, small quanti- 
ties of Vichy given by the stomach seem to be grateful to the 
patient. During this period also the alkaline treatment, which will 
be spoken of, may be inaugurated ; and finally we may, toward the 
close of the attack, if this is possible, give a vigorous cathartic, such 
as cascara, or Rochelle salts. 

In the intervals between the attacks these patients do best on the 
following treatment : The bowels should be kept in a normal condi- 
tion ; if the child is constipated a rectal enema should be given daily, 
and, if this is not effective, it should be supplemented by some 
catharthic, such as cascara, in order to facilitate a complete daily 
evacuation of the bowel. The diet in these children should be a 
mixed one. I have found that whereas some of these children will 
not tolerate cereals others will. The rule, however, is that we 
should reduce the quantity of milk, especially in the older children, 
to a minimum, and, if possible, place the patient on a diet in which 
milk enters but little. They should be placed, so far as medicinal 
agents are concerned, on the so-called alkaline treatment, which has 



462 DISEASES OF THE DIGESTIVE SYSTEM. 

been found to be most successful in these cases. For a child from 
three to five years of age I prescribe a powder composed of 2 to 3 
grains of bicarbonate of soda and J to J grain of carbonate of lithium. 
This powder is given three times daily after meals in a glass of 
Vichy Celestins. The children are bathed daily in a bath in which 
a handful of bicarbonate of soda and a handful of salt have been dis- 
solvedj and are rubbed down after the bath with a very dilute solu- 
tion of alcohol in water and a rough towel. The muscles of the 
body are kneaded, if a masseuse is available. Sojourn in the open 
air as much as possible is advised, and sports which involve mus- 
cular exertion encouraged. Regularity at meals is inculcated, and 
these little ones are taught, if possible, to evacuate the bowel regu- 
larly. In some of these cases the coarser the diet, the more success- 
ful seems to be the treatment, for in the most aggravated cases that 
I have seen there has been a too " finicky " selection of a few 
articles of diet for these patients, and the little ones have been kept 
in some cases on milk, gruels, and fruits, to the exclusion of every- 
thing else, for months. 

Other Forms of Vomiting. — There are other forms of vomit- 
ing which are of interest in this connection : 

a. Some children vomit when irritated or after outbursts of 
temper, or may vomit at will if their food or anything in con- 
nection with their discipline does not meet their approval. Some 
of the little patients know intuitively that vomiting alarms the 
mother, consequently it will appear whenever any concession is to 
be obtained in the nursery. 

b. Vomiting, especially after eating, may be caused by a severe 
attack of coughing. If vomiting occurs frequently under these con- 
ditions, whooping-cough should be suspected. 

c. The vomiting of pyloric stenosis of the congenital type is 
characteristic. It is more in the nature of a regurgitation. When 
lying on the back the baby vomits at intervals, and in small quan- 
tities. After a nursing there is an interval, after which the infant 
vomits two or three times the amount of food taken at the recent 
nursing. This is explained by the fact that in this condition there 
is some little vomiting constantly going on, due to the increased 
peristalsis of the stomach. There is, however, a small quantity of 
food retained in the stomach. This residual quantity increases with 
each feeding, and is finally rejected in the manner just described. 

d. The vomiting of appendicitis is also characteristic. The patient 
is seized suddenly with sharp abdominal pain and then begins to 
vomit. The vomiting may recur once or twice, and then cease. In 
neglected cases, in the final agonal stage, vomiting due to sepsis and 
toxaemia may be persistent. 

e. Vomiting is the first symptom in intestinal obstruction. It 
may be followed by a very small movement, and then for a short 



COLIC. . 463 

time there is, as a rule, no action on the part of the l)owels. The 
vomiting may not recur in the first twenty-four or forty-eight hours, 
except at long intervals, but the bloody movements recur frequently, 
and pain is also present. The vomiting returns when the intussus- 
ception is more marked, and late in the affection becomes fecal. 

/. Vomiting occurs at the outset of the infectious diseases. Per- 
sistent vomiting extending over a period of months is often of 
nephritic origin. 

g. The vomiting which accompanies meningitis occurs at the out- 
set in that of the cerebrospinal type, and is quickly followed by 
cerebral symptoms. In tuberculous meningitis it occurs at the onset 
and after the appearance of a vague series of cerebral symptoms. 
It is rarely persistent after the initial attack. The subsidence of 
the vomiting and the sequence of cerebral symptoms and a febrile 
movement will easily distinguish this form of vomiting from 
others. 

Tumor and abscess of the brain are accompanied by vomiting at 
intervals. 

Colic. 

Colic is not a disease, but a symptom of disturbed conditions of 
the gut. It is really a painful contraction of the muscle-fibre of 
portions of the gut- wall. In the simplest form the painful contrac- 
tions are incited by actual distention of the lumen of the gut. The 
pain caused in colic is in the majority of cases not of the character 
which arises in certain other affections of the gut which are neurotic 
in nature, nor is it of the same nature as that seen in enteritis. Pain 
similar to that in colic may be caused by the administration of some 
such drug as lead, arsenic, etc. 

Cause. — In the great majority of cases the affection is caused by 
some disturbance of the processes of assimilation in the gut. It is 
uncommon in infants in good condition, and its appearance in any 
case indicates the necessity of an investigation into the condition of 
the digestive processes in the stomach and intestine. The form of 
pain or colic accompanied by distention (tympanites) seen in new- 
born infants, and also at the height of pneumonia in older children, 
has an etiology distinct from that of the ordinary variety. Not 
only is the pain of neurotic origin, but also the distention is a 
result of paralysis of the muscular fibre of the gut. The pro- 
cesses in the gut may be disturbed as a result of the pneu- 
monia. Colic may occur in breast-fed or in artificially fed infants. 
In the former it is not always possible to discover the exact 
cause. The breast milk may be abundant, of good color, and of 
correct composition, and still there may be very violent colicky 
pains. In artificially fed infants the cause of the colic may lie in 
the very nature of the food (cowls' milk) and the difficulty of com- 



464 DISEASES OF THE DIGESTIVE SYSTE3I. 

plete assimilation. Thus not only will an excess of proteids in the 
milk cause colic ; the nature of the proteids of cows' milk, no matter 
how much they are diluted, will cause colic. An attack of colic 
is preceded by general uneasiness ; the infant cries and cannot be 
quieted. The severe colicky pain is accompanied by sharp cries, the 
arms and lower extremities are drawn up, and the abdomen is rigid. 
After the passing of gas the infant is quieted and falls asleep quite 
exhausted. These attacks of colic deprive the infant of sleep ; they 
may or may not be accompanied by tympanites. The movements 
are rarely normal, or may be normal for some days and then take on 
a curdy character or become greenish. Sometimes the colicky attacks 
are accompanied by a mild form of diarrhoea ; the pain may be so 
severe as to cause convulsions. 



Tympanites. 

Tympanites is a condition of distention of the gut with gas, which 
may supervene in inflammatory states of the peritoneum. In such 
conditions (peritonitis, appendicitis) the paralysis of the muscular 
wall of the gut is the real cause of the distention. In other states, 
such as pneumonia, it may be the result of inefficient action of the 
diaphragm and of an enteric catarrh which sometimes accompanies 
that disease. In the newborn infant, tympanites is a result of 
an inherent muscular weakness of the intestinal wall. In colic 
due to imperfect assimilative processes in the gut, the tympanites 
is due to the formation of gases of which the intestine is unable to 
rid itself rapidly. 

In pneumonia the tympanitic distention is sometimes extreme, 
causes great distress, and is frequently mistaken for peritonitis. In 
the forms of distention in the newborn infant the distress is not so 
great. In rachitis there is a state of tympanitic distention of the 
abdomen due not only to defective assimilative processes, but also to 
a lax condition of the muscle-fibre of the intestinal walls. 

Treatment of Colic and Tympanites. — If the food of a bottle- 
fed infant is at fault, the modification of milk must be altered so 
that the proportion of the proteids may be lower. A reduction of 
proteid will not always remedy the condition ; the proportion of 
sugar is sometimes at fault, especially in infants fed on condensed 
milk. Not more than 6 per cent, of sugar should be added to any 
milk modification. Some infants can take a large quantity of malt- 
sugar in their food and not suffer from colic. If a breast-fed infant 
suffers from colic, the hygiene of the nurse should be attended to. 
If after the taking of exercise and regulation of diet the colic persists 
and becomes a feature in the case, the wet-nurse should be changed. 

The attack of colic is best combated by giving the infant an enema. 
In some cases a small amount of dilute hydrochloric acid and pepsin 



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DILATATION OF THE STOMACH. 465 

given three times daily will alleviate the symptoms. If in spite 
of all efforts an artificially fed baby suffers with colic and does not 
increase regularly in weight, it should be placed at the breast. 

Dilatation of the Stomach. 

Etiology. — Dilatation of the stomach may be due to mechanical 
causes, such as stenosis of the pylorus, resulting in overfilling of the 
stomach, with consequent dilatation ; or it may be caused by muscu- 
lar atony, such as is present in general atrophy or rachitis. In 
mechanical stenosis of the pylorus the muscular structures are intact 
at first ; hypertrophy subsequently appears in the region of the pylo- 
rus, with secondary dilatation of the fundus of the stomach. An 
hour-glass distortion of the form of the stomach and, subsequent to 
this, a sausage-shaped dilatation of the organ result, the long diam- 
eter of the dilatation being in the long axis of the stomach. This 
last-named deformity is permanent. 

The location of a dilated stomach in the child differs somewhat 
from that in the adult. The pylorus in the child lies deepest and 
near the umbilicus in the mid-line ; the fundus lies transversely 
across the abdomen at the situation of the umbilicus ; whereas in the 
vicinity of the border of the ribs it passes abruptly upward. The 
muscular coat of the stomach in these cases is thin and atrophic. 
If there is overloading of the stomach, or the ingestion of indigest- 
ible substances, the organ is not thoroughly emptied, and as a result 
there are fermentation and accumulation of food in the stomach. 
Muscular relaxation results, and then atrophy of an otherwise weak 
musculature. In athrepsia and rachitis the musculature of the 
stomach is primarily weak, and repeated attacks of dyspepsia with 
overloading result in dilatation. 

The symptoms of dilatation of the stomach as a result of pyloric 
stenosis are described elsewhere. As a result of chronic dyspepsia 
and overloading of the stomach in younger children there are at 
first the ordinary symptoms of evanescent dyspepsia. There is vom- 
iting after meals, and after a time this vomiting takes place after 
the food has accumulated in the stomach. With the attacks of vom- 
iting .there is loss of appetite, and finally an intolerance of all food, 
even in very small quantities. Constipation follows as a result of 
lack of appetite and the avoidance of food. Meteorism is present in 
some of these cases ; whereas in others intestinal catarrh may alter- 
nate with the constipation. 

In older children dilatation of the stomach results from repeated 
attacks of dyspepsia which extend over months. The development 
of the disease is slow. There are loss of appetite, a feeling of tension 
and overloading after meals ; the odor of the breath is bad ; the 
tongue is coated ; children complain of headaches ; the bowels are 
30 



466 DISEASES OF THE DIGESTIVE SYSTEM. 

very irregular, sometimes constipated ; and finally vomiting after 
meals sets in. The vomited matter contains not only particles of 
food, but sarcinse and other species of bacteria. The reaction of the 
stomach-contents may be neutral or acid, the hydrochloric acid and 
propeptone may be increased or may vary on different days ; lactic, 
butyric, and acetic acids may be present in the vomited matter as a 
result of fermentation. 

The physical signs consist of persistent meteorism and tympan- 
ites. The abdomen is very much enlarged, and in some cases the 
stomach can be distinctly outlined, especially the greater curvature. 
If the child is examined lying on its back, with its knees raised and 
the pelvis supported with one hand while the other taps the abdomen 
sharply over the situation of the stomach, the distended organ will 
yield a so-called succussion sound, due to accumulated contents in 
the organ. In many cases a dilated colon may be mistaken for a 
dilated stomach. By means of gastrodiaphany the author has been 
able to mark out quite distinctly the greater curvature of the 
stomach. 

The prognosis will vary according to the exciting cause. If the 
dilatation of the stomach is caused by congenital stenosis of the 
pylorus the prognosis is bad ; if caused by repeated attacks of gas- 
tric dyspepsia the prognosis is more favorable. It is not as favor- 
able in severely rachitic children, in Avhom there may be at the 
same time a progressive atrophy of the muscular tissue of the stomach. 

The treatment of dilatation of the stomach in infants and 
children does not differ materially from the treatment of the 
same condition in the adult. In infants the quantity of solid 
food and fluids given at each meal is reduced to a minimum. The 
systematic washing of the stomach at intervals is indicated in these 
cases, as in older children and adults. With older children the 
amount of fluids is also limited. Soups are excluded and milk 
is peptonized. Bread, meat, and digestible substances are preferred 
to fluids. In these cases also the stomach is washed systematically. 

The medical treatment of these cases consists in the aduiinistra- 
tion of hydrochloric acid, pepsin, general hygiene, massage, faradiza- 
tion of the stomach in severe cases, as in the adult. 

Ulcer of the Stomach. 

Ulcer of the stomach may occur as a complication in sepsis 
of the newborn, in acute gastritis, and in tuberculosis. As a 
primary disease, this affection is very rare in infancy and childhood, 
although cases are reported in the literature as a complication of in- 
fectious diseases, such as scarlet fever, typhoid fever, measles, tuber- 
culosis. Reimer records a case in a child three and a half years of 
age. Hibbard met a case in an infant four months of age. Rotch 



HYPERTROPHIC PYLORIC STENOSIS. 467 

reports a case in an infant seven weeks old. It is rare, however, 
between, the ages of one and ten years. In 226 autopsies Brinton 
saw it twice. I have seen it at an autopsy in a case of empyema. 
It occurs in chlorotic girls toward the age of puberty, and is not a 
disease of infancy and childhood. 

Hypertrophic Pyloric Stenosis. 

( Congenital Stenosis of the Pylorus ; Congenital Hypertrophy of the Pylorus and Stomach- 
wall ; Congenital Gastric Spasm. ) 

Hypertrophic pyloric stenosis is a congenital condition which 
appears from a few days to several weeks (three months) after birth, 
and manifests itself in persistent vomiting. In a few instances several 
infants in the same family have been thus affected. 

The first case of pyloric stenosis was described by Dr. Beardsley 
in the Transactions of the New Haven 3Iedical Society (Osier). 

The etiology of the affection is obscure. Since in the majority 
of the cases which have been carefully studied the infants were over- 
fed or improperly fed, it is supposed that some irritant to the stomach 
is the exciting cause. Thomson, who has made careful studies of 
these cases, believes that the condition originates in intra-uterine 
life, and is due to the ingestion of liquor amnii. This fluid, by 
irritating the mucous membrane of the stomach, excites both that 
organ and the pylorus to overaction. Pfaundler, voicing the teach- 
ings of Escherich's school, denies that there is a true hypertrophy 
of the pylorus, and asserts that the condition during life is that of 
functional spasm. The post-mortem condition is due to toxic 
agonal contracture of the pylorus. 

Morbid Anatomy. — The stomach and oesophagus have been 
found to be dilated in fully one-third of the reported cases. The 
mucous membrane shows the usual changes, such as the congestion 
which is seen in a stomach in which there have been functional dis- 
turbances. The mucous membrane of the pylorus is thrown into 
voluminous folds. The lumen has in some cases been found patent 
to a small probe, but fluids cannot be forced from the stomach through 
the pylorus (Thomson). The muscular fibres show characteristic 
change. The circular fibres are thickened and hypertrophied 
(Thomson). In Finkelstein's case the longitudinal fibres were also 
thus affected. Some deny this hypertrophy and contend that it is 
an agonal contraction. 

Symptoms. — Infants in whom this condition is present are of 
normal weight and appearance when born. As a rule, the desire for 
food is greater than is normal. In the majority of cases the infants 
are allowed, on account of supposed insufficiency of the breast milk, 
to nurse an excessive length of time. It is soon noticed that there 
is vomiting of small quantities of milk after each nursing. After a 



468 DISEASES OF THE DIGESTIVE SYSTEM. 

few days all the food taken into the stomach is rejected, and the 
vomiting attacks increase in frequency. The vomited matter rarely 
contains bile-stained matter, though I have seen a case with bile- 
stained vomitus. At times the amount vomited is less than or about 
equal to the quantities of food ingested at the nursing. At intervals 
attacks of vomiting occur during which more food is rejected than has 
been taken at the preceding nursing. This proves that there is not only 
retention of food, but also lack of absorption by the mucous membrane 
of the stomach. The bowels are either constipated or very little in 
the form of fseces passes through the gut. In some cases a little faecal 
matter resembling meconium is passed ; whereas in other cases the 
stools are greenish, contain mucus and but very little fsecal matter. 
Toward the close the movements may contain mucus. In other 
cases the movements are scanty, but otherwise normal. 

The infants rapidly lose weight ; the abdomen has a characteristic 
appearance in all the cases I have met. The abdominal walls are 
lax, the coils of gut can be clearly made out, and the peristaltic 
movements are visible. In the epigastrium, just beneath the ribs, 
is a large coil, and to the right of this a constricting band and what 
appears to be another coil. These are in constant peristalsis. I have 
seen these coils in two cases, and in both they had been mistaken 
for the stomach. They were, in my opinion, coils of the transverse 
colon. In two of my cases I could on deep palpation in the median 
line, midway between the ensiform cartilage and the umbilicus, feel 
a resistant nodular mass, which may have been the contracted pylo- 
rus. I have not been able to map out a dilated stomach. 

Prognosis. — If the vomiting is unrelieved, death occurs in from 
three weeks to six months. Cautley and Dent have reported 50 
cases of pyloric stenosis, 19 of which died within three or four 
months. Of their own cases, of which they report 7, all died but 
2, and these were operated by means of pyloroplasty, an operation 
which they advocate in preference to other operations. One infant 
weighed 8 pounds when operated on, and was eight weeks old ; 
another weighed 9 pounds and 6 ounces and was six Aveeks old. 
On the other hand, all of the cases not operated on are not hopeless. 
Heubner has seen three cases Avhich recovered. I have seen three 
cases in which the history, symptoms, and physical signs were un- 
doubtedly those of congenital stenosis, and all recovered. One case 
gained to a remarkable degree in weight, another in three months 
contracted gastro-enteritis and subsequently a terminal intussuscep- 
tion and died unrelieved ; the third recovered. 

Treatment. — All mouth-feeding should be suspended. The in- 
fant is kept in the recumbent position, and the stomach washed out 
once ; all binders and constricting clothing are removed from the 
abdomen. The infant is then fed by the rectum for one or more 
days with small quantities of album in- water, or an ounce of 



ACUTE GASTRO-ENTERITIS. 469 

somatose solution is introduced per rectum three or four times daily. 
This amount, although seemingly small, will if retained, sufficiently 
nourish the patient. The stomach is thus given complete rest. After 
two days teaspoonful doses of albumin-water are given by mouth 
every hour, and are supplemented by rectal enemata. If the vomit- 
ing has diminished or ceased, artificially fed infants are given by 
mouth a very dilute milk modification (0.5 of proteids, 2 of fat) in 
half-ounce doses, pasteurized or sterilized. The milk is given alter- 
nately with albumin- water. Milk is at first given only three times 
in the twenty-four hours alternately with albumin-water. If vomit- 
ing recurs, mouth-feeding is again suspended and rectal alimentation 
substituted. The infant is not moved, especially after being fed. 
In this tentative way, gradually increasing the quantity and strength 
of the milk (1.2 of proteids, 2.5 of fat), I have succeeded in three 
cases in effecting tolerance of food and cessation of vomiting. 

Medicines are of little value in these cases. I have used small 
doses of bismuth subnitrate in combination with pepsin, to allay 
the irritability of the stomach. 

Surgical Treatment. — Two surgical procedures have been proposed 
and attempted in these cases. The first method is that of opening 
the abdomen and establishing a communication between the stomach 
and gut by means of a Murphy button. This procedure, first sug- 
gested by Schwyzer, was carried out by Willy Meyer on the case 
of Meltzer, with fatal results. The second method is that adopted 
by Nicoll in the case of Eitchie. The abdomen was opened, an 
incision made near the pyloric end of the stomach, the pylorus 
forcibly dilated with forceps, and the wound closed. The infant 
recovered. I believe that with these weak infants every expedient 
should be tried before resorting to surgical intervention. 

Acute Gastro- enteritis (including Cholera Infantum). 

{Summer Diarrhoea; Acute Gastro-enterie Infection.) 

Acute gastro-enteritis is a form of diarrhoea usually accompanied 
by gastric symptoms. It is prevalent in the summer, but may also 
occur during the winter months. Bottle-fed infants are more subject 
to the affection, although it occasionally attacks infants at the breast. 
In institutions epidemics of gastro-enteritis occur in breast-fed in- 
fants. In large cities more than one-half the deaths among infants 
under the age of twelve months are caused by summer diarrhoea. 
In Paris, Chaterinkoff found that of 20,000 children dying of 
gastro-intestinal disorders, fully three-fifths were bottle-fed. This 
high rate of the mortality of bottle-fed infants, as compared with 
that of breast-fed infants, is not alone due to the difference in the 
nature of the food ; no matter how carefully it is handled before it 



470 DISEASES OF THE DIGESTIVE SYSTE3I. 

reaches the infaDt, milk passes through many channels, and in each 
of these it is exposed to infection. The intense heat of summer 
also favors the increase of infectious agents. 

Classification. — The various forms of acute gastro-intestinal in- 
fection may be divided into those whose source of infection lies out- 
side the body (ectogenous) and those in which the elements of 
infection are pre-existent in the body (endogenous). This classi- 
fication (Escherich) of the diarrhoea of infancy is both practical and 
in accordance with the results of recent study. In the first class 
are included the diarrhoeas of toxic origin and cholera infantum ; in 
the second are included the diarrhoeas which are caused by varieties 
of bacteria pre-existent in the gut, but which, in the opinion of 
Booker, Escherich, and Marfan, may under favorable conditions 
increase to enormous numbers and become virulent. According to 
Booker, no one specific micro-organism is the essential cause of 
gastro-enteritis or acute summer diarrhoea. Escherich has shown 
that the coli group may under certain conditions become virulent. 
Of the bacteria which are found in certain forms of gastro-enteritis, 
the Streptococcus enteritidis seems to have attracted the greatest at- 
tention. Booker first insisted on the importance and peculiar role of 
this micro-organism. He found these streptococci in great numbers 
not only in the stools of infants suifering from acute summer 
diarrhoea, but also in the walls of the gut and in the various organs 
of the body. Escherich, Libman, and Hirsch have confirmed the 
results of Booker. Escherich regards the Streptococcus enteritidis as 
an ectogenous infection. The udder of the cow may be the source 
of this micro-organism. Marfan and Booker are also inclined to 
believe that streptococci are able under certain conditions to increase 
in number and virulence and that they are one of the endogenous 
forms of infection by a micro-organism normally present in the gut. 
Among the other bacteria found in enormous numbers in the move- 
ments of infants and children suffering from acute gastro-enteritis 
are the Bacillus pyocyaneus (Kossel and Baginsky), Proteus vul- 
garus (found by Booker in choleriform diarrhoea), and the proteolytic 
bacteria. The last class comprises peptonizing bacteria, such as 
the Bacillus subtilns. Bacillus mesentericus vulgatus, and Tyrotrix 
tenuis. These peptonizing bacteria are not found in the gut or 
stools of the breast-fed infant either when in good health or sick. 
We may thus classify all diarrhoeas of acute gastro-enteritis as 
follows : 

1. Those due to improper food, or the so-called mechanical irrita- 
tive diarrhoeas (Booker). 

2. The infectious form of gastro-enteritis (endogenous and ectog- 
enous). This class would include the toxic diarrhoeas of some 
authors. 



ACUTE G ASTRO-ENTERITIS. 471 

Not only the food and the bacteria, but also certain changes in 
the gut play an important role in acute gastro-enteritis. 

Morbid Anatomy — Stomach and Intestines. — Booker has 
described a superficial loss of the epithelium of the stomach and gut, 
as a constant lesion in all fatal cases of gastro-enteritis. It may be 
intact in some places and destroyed or eroded in others. The 
mucous membrane of the jejunum and duodenum may show less 
denudation than other parts of the gut. The epithelial layer 
of the mucosa is infiltrated with leucocytes in diffuse areas or nests. 
The infiltration may push the epithelial layer upward. The mucosa 
itself is infiltrated with polynuclear and mononuclear leucocytes to a 
varying extent. The mucosa shows superficial or deep ulcerations 
involving the crypts or villi. Heubner has described a form of 
necrosis which chiefly affects the epithelial structure without involv- 
ing the deep mucosa. This occurs in cholera infantum. Booker 
also describes a bronchitis and a form of bronchopneumonia which 
are quite constantly found in fatal cases of gastro-enteritis. Hem- 
orrhages into the lung tissue are common. 

In the kidneys there is necrosis of epithelium in the convoluted 
and irregular tubules (Booker). 

The liver shows fatty degeneration and necrosis of the liver-cells. 

The lymph-nodes show focal necrosis. 

The Role of the Bacteria. — Booker has demonstrated that no 
bacteria are found in the mucosa of the intestine if the superficial 
epithelium is intact. If there is a lesion of continuity of the super- 
ficial layer, the bacteria invade the mucosa in large numbers. There 
is reason to believe that the toxins generated by the bacteria in the 
gut cause the superficial erosions and prepare the way for invasion 
of the lymph-channels and bloodvessels. Bacteria are not always 
found in the lesions, but as a rule the ulcerations of the mucosa 
show vast numbers. Booker found bacteria in cultures taken from 
the solid organs and blood, thus confirming what Czerny and Mozer 
found to be the case during life. The lungs especially showed large 
numbers of bacilli and cocci. 

Symptoms — In the mild form of gastro-enteritis the infant is 
restless and cries at intervals because of colicky pains. It may pre- 
viously have been in good health, but with the advance of these symp- 
toms there will also be noticed a slight febrile movement and a disin- 
clination to take the bottle or breast. Vomiting occurs after feeding, 
the rejected contents of the stomach being curdled and having a 
marked acid odor. In mild cases the vomiting is usually not severe. 
It may be repeated three or four times in the twenty-four hours. 
The movements are at first normal ; they afterward become frequent 
and contain whitish curds or greenish and white curds, are more fluid 
than is normal, and may have a very ofiiensive odor. In mild cases 



472 DISEASES OF THE DIGESTIVE SYSTEM. 

there may be only two or three such movemeuts in the twenty-four 
hours or they may number six or more. Later, the fever also 
becomes more marked, the temperature sometimes mounting as high 
as 103° F. (39.4° C). If the feeding is continued, the vomiting 
persists. The infant shows little or no prostration. 

In severe cases the vomiting, is marked from the outset. The 
infant not only vomits its regular food, but will also often vomit all 
fluid that is taken into the stomach. The diarrhoea is also more 
severe than in the mild forms. The movements are at first yellow 
or greenish and contain white curds, but as the disease advances 
they become more fluid, until in very severe cases only a greenish 
malodorous liquid containing small particles of mucus and fecal 
matter is voided. The infant has a febrile movement which varies 
from 101° to 103° F. (38.8° to 39.4° C), and there is marked 
prostration. In the acute forms of gastro-enteritis there is con- 
siderable loss of weight ; the infant becomes pale and languid, and 
the pulse is rapid and weak ; the number of daily evacuations may 
reach twenty. In some cases the straining causes a descent of the 
lower part of the rectum, and the movements contain a slight 
amount of bloody mucus. The odor of the evacuation may not 
be offensive. If the patient improves, the symptoms retrograde 
— the vomiting becomes less frequent, the stools more fecal in char- 
acter and less numerous, and the fever subsides. If, on the other 
hand, the symptoms progress, the movements not only continue fre- 
quent and fluid, but also blood and particles of mucus are mingled 
with the fecal matter. The vomiting may cease entirely. The in- 
fant loses in weight steadily ; the movements are small and passed 
with tenesmus ; the patient passes into the subacute stage of gastro- 
enteritis. In some cases there is colic ; the infants are restless or 
pass into an apathetic condition. Little urine is passed, and in the 
majority of cases of mild or severe gastro-enteritis, albumin is 
present. It rarely amounts to more than a trace. In severe cases 
there are leucocytes and epithelial, hyaline, and blood-casts in the 
urine ; sometimes in addition a few blood-cells are found. 

In the subacute forms of gastro-enteritis which last for more 
than a week, bronchopneumonia may be a complication. This form 
of bronchopneumonia is described in the section on Pneumonia. In 
some cases it is of short duration, in others persistent. Broncho- 
pneumonia with slowly resolving areas of consolidation in the lung 
is the type met with. 

Course and Prognosis. — The prognosis of the mild forms of 
gastro-enteritis is good, if proper measures are adopted. The severe 
forms are exceedingly fatal in summer. The mortality varies with the 
environment. In the crowded tenements of large cities and in un- 
hygienic surroundings the mortality is great, as is also the case in 



CHOLERA INFANTUM. 473 

institutions and hospitals. In private practice the isolation of the 
patient and special nursing reduce the mortality to a minimum by 
preventing reinfection. Reinfection is caused by lack of care in 
handling the diapers and in preparing the food, by giving improper 
food, and by placing a number of cases in the same room. There 
can be no question that in hospitals patients are affected unfavorably 
by proximity to other patients suffering with the same disease. No 
matter how careful the nursing under such circumstances, reinfection 
cannot be prevented. Also, perfect cleanliness is not attainable 
in hospitals as in private practice. 

Cholera Infantum. 

Cholera infantum is the severest form of summer diarrhoea prev- 
alent among infants. It is believed that it has a specific origin, 
but this has not as yet been demonstrated. Cholera infantum does 
not occur so frequently as has been hitherto supposed. Of hundreds 
of cases of gastro-enteritis of the acute variety which come under 
my care yearly, only a few can be called typical of this form of 
infectious diarrhoea. These cases occur for the most part in weakly 
bottle-fed infants. Breast-fed infants may occasionally be affected, 
especially in hospitals. 

Symptoms. — The infants as a rule have been suffering from a 
mild diarrhoea. Following a slight febrile movement, vomiting and 
diarrhoea of a severe and exhausting character set in. The bowel 
movements are frequent, but contain very little fecal matter after the 
first few have been passed. They are at first greenish, afterward 
becoming watery, resembling barley-water ; they contain but a few 
flocculi of mucus, and may not have much odor. The vomiting is 
incessant. First the stomach contents are vomited, and finally a 
greenish fluid. Within a few hours the infant is reduced to a con- 
dition of great prostration. The loss of weight is marked, even in 
the first twenty-four hours. The skin on the thighs is wrinkled. 

The face and trunk are pale and the face is drawn. There is 
fever to a marked degree (101°-103° F., 38.3°-39.4° C), and 
the pulse is rapid and thready. Toward the close the movements 
are passed involuntarily. The whole picture is that of a choleriform 
disease. As the fatal issue approaches the eyes become sunken and 
glassy, the fontanelle is depressed, and the mouth is open. The con- 
dition described elsewhere as hydrocephaloid sets in. Convulsions 
and a rise of temperature (105° to 107° F., 40.5° to 41.6° C.) 
precede the fatal issue. 

Occurrence. — These severe choleriform diarrhoeas resemble 
Asiatic cholera very closely, and should be sharply differentiated 
from severe forms of gastro-enteritis. They occur in bottle-fed 



474 DISEASES OF THE DIGESTIVE SYSTEM. 

infants under the age of two years, and chiefly in the months 
of July and August. Heat and infected food are the main 
etiological factors. A diarrhoea of a mild type is the forerunner 
in the majority of cases. These cases are not so frequent 
to-day as they were in the days when infants were fed with 
decomposed milk containing bacterial toxins. This form of 
diarrhoea must therefore be looked upon as a purely ectogenous 
infection. 

Duration and Prognosis. — The prognosis in the majority of 
cases of cholera infantum is grave. The disease is an exceed- 
ingly fatal one, occurring as it does for the most part in infants fed 
on the bottle and whose general condition is poor. It lasts for from 
twenty-four hours to two or three days. The rapidity of the devel- 
opment of the symptoms and of the fatal results precludes the possi- 
bility of any complications other than those due to the great drain 
on the system. The condition of hydrocephaloid is hardly a com- 
plication ; it is a terminal set of cerebral symptoms. Sclerema, 
mentioned by some authors, I have not met in true cholera infantum ; 
it is seen in the terminal stage of acute forms of gastro-enteritis. 
This form of sclerema affects the thighs at the upper and inner 
part. It is described in the section devoted to that subject. 

Kjelberg, Felsenthal, Bernard, Morse, and the author, found 
albumin and casts in the urine of children suffering from all forms 
of gastro-enteritis, acute and subacute, including cholera infantum. 

Morse as well as the author found that the urine was concentrated 
and contained hyaline, granular, and epithelial casts, with leucocytes 
and blood and blood-casts. The albumin is rarely present to a 
marked degree. It is a trace or a distinct reaction. The urine is 
suppressed in severe cases, and lessened in quantity in others. In 
some cases of gastro-enteritis of the severe types there is slight 
oedema of the subcutaneous tissues, especially on the inner part of the 
thighs, the legs, and dorsum of the foot. We are not in a position 
to trace any close relationship between the general symptoms and 
the disturbances of the kidney. The toxaemia in this disease, caus- 
ing as it does vomiting and nervous symptoms, masks the nephritic 
symptoms if they are present. 

The diagnosis of acute gastro-enteritis is not difficult. There 
are, however, many infectious diseases, the onset of which closely 
resembles that of an attack of gastro-enteritis. Scarlet fever, for 
example, begins with vomiting, and in some cases with diarrhoea. 
There is a form of grippe which in its onset, with vomiting and 
diarrhoea, closely resembles an attack of gastro-enteric disease. In 
fact, these symptoms may persist in the course of the former affec- 
tion. 

The physician should not be satisfied with a history of gastro- 



CHOLERA INFANTUM. 475 

enteric symptoms, but should carefully examine the skin, throat, 
and chest at every visit. In the severer forms of diarrhoea a small 
particle of the movement may be spread on a cover-glass and ex- 
amined for an excessive number of streptococci. In mild forms of 
diarrhoea we should not fail to make a Widal test of the blood and a 
count of the leucocytes, to eliminate the possibility of typhoid fever. 
This will especially be indicated in cases in which there is enlarge- 
ment of the spleen. 

Treatment of Acute Gastro-enteritis and Cholera Infantum. — 
Prophylaxis. — The nursing bottles when emptied by the infant 
should be filled with a saturated solution of sodium bicarbonate, 
allowed to stand for a few hours, and then carefully washed inside 
and out with a bristle brush. The nipples should be sterilized daily. 
The nurse or mother, after attending to the diapers of the infant, 
should carefully cleanse the hands before feeding the baby. The 
milk should be diluted as directed in the section on Infant Feed- 
ing, pasteurized or sterilized, and then kept on ice until needed. It 
should be obtained from a dairy in which cleanliness of the utensils 
and in the milking of the cows is observed in all details. The milk 
should be fresh and delivered for modification within a few hours 
of the milking-time. The nursings should be conducted at stated 
intervals. If there is a residue in the nursing bottle, it should not 
be utilized for a subsequent nursing. The infant is given a full 
bath daily. By attending to all these details, infection of the food 
and of the infant may be avoided. With breast-fed infants prophy- 
laxis is of great importance. A baby at the breast should be fed 
at regular intervals. The breast-nipples should be washed with a 
saturated solution of boric acid before and after nursing. The baby 
should not be allowed to nurse a breast with a fissured nipple. 
The milk of such a breast is pumped off, and an attempt is made 
to heal the nipple in the manner elsewhere described. If there is 
caking of the breast, the condition should be remedied before the 
infant is allowed to nurse. Abundance of fresh air and bathing are 
indicated in these infants as in bottle-fed infants. 

Sick Infants. — As soon as a baby shows signs of even mild dys- 
pepsia or gastro-enteritis the milk should be discontinued, a simple 
cathartic given, and the infant kept for twenty-four hours on a 
solution of egg-albumin. Vomiting which has occurred only once 
or twice does not call for active treatment, as it will disappear as 
soon as the milk is discontinued. After the bowels have moved, if 
the infant shows no exacerbation of symptoms feeding should be 
resumed cautiously. In this way a severe gastro-enteritis can be 
averted. If the food is not suitable, causing signs of dyspepsia 
such as colic, it should be changed if possible, else severer symptoms 
may result. If in spite of all precautions an attack of gastro- 



476 DISEASES OF THE DIGESTIVE SYSTEM. 

enteritis develops, the patient should be treated on the following 
lines : 

1. The food is stopped and another of a safe character substi- 
tuted. 

2. The toxins are eliminated and the strengh of the patient sup- 
ported by the so-called mechanical methods. 

3. Drugs are used to abate the symptoms and support the 
strength of the patient. 

The milk, whether of the breast or bottle, is discontinued. The 
infant is given a solution of albumin-water, acorn-cocoa, or beef- 
juice expressed and diluted with barley-water. A baby can be kept 
for days upon these mixtures without any danger of reducing the 
strength. 

According to Czerny, 100 c.c. of breast milk are equivalent to 61 
calories; 100 c.c. of the white of egg are equal to 75.1 calories. 
The white of one egg weighs about 30 grammes ; therefore the white 
of an egg is equal to about 25 calories. It is digestible, and is well 
borne by infants. Albumin-water may be used alternately with the 
solution of acorn-cocoa or beef-juice and barley-water. To older 
children who are suffering from gastro-enteritis we may sometimes 
have difficulty in administering albumin-water or acorn-cocoa. Under 
such conditions I frequently resort to a dextrinized gruel or the so- 
called Liebig's soup mixture which Keller advised. I find that 
after the acute symptoms are past, infants and children who refuse 
every other form of food will take this with eagerness. It may be 
given while the diarrhoea is still in progress, but should not be given 
until the vomiting has ceased. 

The cathartic given at the onset should be castor oil or calomel, 
J grain (0.03) doses twice or three times a day. Infants who are 
vomiting are given calomel in preference to castor oil. 

The Vomiting. — If the vomiting is not severe and the case is 
under treatment from the onset, it is best not to wash out the 
stomach at once. It often happens that the vomiting ceases as soon 
as the regular food is stopped. If, however, the vomiting persists 
for twenty-four hours, Ave proceed to wash out the stomach once. 
If the vomiting continues after this, it is either toxic or may in 
rare cases be due to some other causes. As a rule, it ceases after 
one irrigation of the stomach. 

The diarrhoea is controlled by irrigation of the gut. The rectum 
and gut are washed out in those cases in which the diarrhoea is not 
only persistent, but progressive. The object in washing out the 
lower bowel in any form of acute gastro-enteritis is twofold : (a) 
to remove any residue of feces that may have collected in the lower 
bowel and rectum, and to stimulate peristalsis and thereby favor 
evacuation from above ; (6) to stimulate the heart and add to the 



CHOLERA INFANTUM. 477 

body an amount of normal solution to compensate for the drain 
caused by the diarrhoea. The Cantani normal salt solution is 
utilized in the manner described on page 68. 

The rectal enemata are given under a pressure obtained by an 
elevation of at most two feet from the bed. A temperature of 107° 
to 110° F. (40.5° to 43.3° C.) is the best and most stimulating in 
these cases. Fully a quart of water is thrown into the rectum in 
half-pint portions. As the half-pint flows in, the funnel on the 
rectal tube is disconnected and the contents of the bowel are allowed 
to escape. Another portion is then allowed to flow into the bowel. 
The water will sometimes escape alongside of the tube. This is 
rather a favorable sign, being significant of the contractile powers 
of the gut and abdominal walls. Only two enemata daily are neces- 
sary, even in severe cases of acute gastro-enteritis. As the diarrhoea 
and symptoms subside we reduce the number of enemata to one, 
finally discontinuing them entirely as the infant improves. It 
sometimes happens that after a few days the enemata are followed 
by movements containing blood and mucus, the tenesmus being 
aggravated. In these exceptional cases an enema must be given 
only every other day, and the effect on the rectal discharges watched. 
By stopping the enemata altogether it can be determined whether 
the discharges of mucus and blood are caused by the therapy or the 
disease. 

Hypodermoclysis. — The injection of normal salt solution under 
the skin is indicated only in the severe cases of acute gastro- 
enteritis in which, as in cholera infantum, the course of the disease 
is rapid and the prostration extreme. Personal experience rather 
discourages the employment of large injections by this method. I 
have seen two cases of infection by the Bacillus capsulatus aero- 
genes (Welch) following hypodermoclysis. These occurred through 
the use of saline solution evidently insufficiently sterilized, and 
which had probably been allowed to stand before being used. In 
a third case hemorrhages over large areas occurred at the point of 
the injection of the salt solution. These injections are also very 
painful. Because of these dangers and disadvantages the subcuta- 
neous injections of salt solutions should be utilized as a last resource 
in desperate cases. Small rather than large amounts of fluid should 
be injected subcutaneously, as was advised on page 36. The salt 
solution for the hypodermoclysis is that of Cantani. It should be 
sterilized at a temperature of 212° F. (100° C.) for at least an 
hour, to kill sporulated bacteria if possible. A very fine hypodermic 
needle is used in the manner described on page 62. 

Baths. — In all cases of acute gastro-enteritis, w^hether with or 
without elevation of temperature, the benefit obtained from warm 
baths cannot be overestimated. In cases of great prostration a bath 



478 DISEASES OF THE DIGESTIVE SYSTEM. 

at 108° F. (42.2° C.) for five minutes is stimulating to the nervous 
centres and is followed in many cases by diminution of the apathy 
and an apparent reduction of the effects of toxaemia. If the tem- 
perature rises above 103° F. (39.4° C), sponging with water at 
80°-85° F. (26.6°-29.4° C.) is all that is needed. This should 
not be done oftener than once in every three hours. 

Alcohol. — Of late years, whiskey is given less and less in cases 
of acute gastro-enteritis. In these cases there is a special intoler- 
ance of the stomach and also of the economy to whiskey. Infants 
after taking it for twenty-four hours will become stupid, apathetic, 
and exhibit a constant retching if they do not vomit. This appears 
to be due more to the effect of the alcohol locally on the stomach 
and also systemically than to toxaemia of the disease. I therefore 
deprecate the use of alcohol except in extreme cases, when whiskey 
is given in small doses at short intervals. 

Strychnine is useful for its stimulating effect on the heart. Grain 
-g^Q- (0.0002) is given to an infant of six months, and grain -^^-^ 
(0.0003) to older infants every three hours. 

Atropine, lately advised as a cardiac stimulant in these cases, 
especially in cholera infantum, is a dangerous drug, and should not 
be employed. I have seen grain j^-^ (0.0004) give rise to constant 
tremulous and convulsive twitching. 

Resorcin. — If the vomiting is constant, grain J (0.008) of 
resorcin given every three hours is a safe and very useful remedy. 
It should never be used in larger doses nor at shorter intervals. 

Bismuth in the form of the subcarbonate is the only drug useful 
in allaying the vomiting and the tenesmus of the bowel. Grains ij or 
iij (0.12 or 0.18) are given in powder form every two or three hours. 

Opium in any form has fallen into disuse. In the severe cases it 
is dangerous, and may increase the prostration ; in the milder cases 
its use is justifiable only if the colicky pains are excessive. The 
milder preparations such as the wine and the camphorated tincture 
are of value, because they can be given in graduated doses, and the 
effects determined more exactly than can be done with the stronger 
preparations. 

Salol in grain J (0.03) doses every three hours may be combined 
with the bismuth to allay the colicky pains. 

Tannigen is a useful drug in the chronic forms of intestinal dis- 
ease, but an irritant in the acute forms. 

Colic has been mentioned so often that a few words as to the 
treatment may not be out of place. Passing of the rectal tube rarely 
relieves it. A small rectal enema has been found to be a very 
effective remedy. 

As the symptoms improve care should be taken not to return to 
a milk diet too quickly. The milk is given in dilutions and is 



INFANTILE ATROPHY. 479 

sterilized carefully. Infants in an enfeebled condition as a rule 
bear this form of milk best, since it is not apt to be irritating to the 
gut. When the danger is past any form of milk may be given — 
raw, pasteurized, or sterilized — care being taken that all the pre- 
cautions as to freshness, cleanliness, and proper preparation are 
observed. I have mentioned the fact that before returning to 
dilutions of milk the exhibition of dextrinized gruels has been suc- 
cessful with very weak infants. The malt, the cereal, and the milk 
acted upon by the ferment contained in these mixtures are all easily 
digestible and assimilable, and promote increase of weight. As a 
matter of course, the effect of the gruel mixture on the stomach and 
gut should be carefully studied. 

Whatever methods are employed in the treatment of acute gastro- 
enteritis, it is necessary to avoid the error of overtreatment. It 
should be remembered that hours of rest do more than hours of 
treatment. Three-hour intervals should elapse between the appli- 
cation of remedial measures. Fresh air in the room or a sojourn 
of a few hours in the open with absolute quiet, is of the greatest 
value in these cases. 

Infantile Atrophy. 

{Marasmus; Athrepsia (Parrot).) 

Atrophy may follow or complicate congenital syphilis or any 
subacute or chronic disease of the gut. Infantile atrophy, or the 
athrepsia of Parrot, is a condition due to a faulty operation of the 
assimilative processes in the gut. 

The etiology of chronic atrophy is unknown. Keller, who has 
studied this condition extensively, believes that in infants and 
children suffering from gastro-enteric catarrh there is an excessive 
production in the gut of acids which under normal conditions are 
neutralized. In disturbed conditions, instead of urea, ammonia is 
excreted in the urine. The formation of the ammonia entails a 
drain on the economy — hence the emaciation. Excess of albumi- 
noids and fats in the food favors overproduction of acids in the gut. 
In marasmus there is an acid intoxication of the economy, origi- 
nating in the gut. There is no doubt that under unhygienic con- 
ditions and in overcrowded hospitals infection of one patient by 
another may take place. No satisfactory explanation of the manner 
in which such infection occurs has as yet been advanced. Heubner 
has surmised that the excreta of one patient in some way contami- 
nates the food of another by transmission through the nursing per- 
sonnel. This is true in a certain number of cases, but not in all. 
Cases of marasmus seen in private practice show progressive emacia- 
tion in spite of the fact that the utmost care is exercised in the 
preparation of food and the strict maintenance of hygienic condi- 
tions. 



480 DISEASES OF THE DIGESTIVE SYSTEM. 

Morbid Anatomy. — The body is much emaciated; the skin 
hangs in folds on the extremities^ and presents hemorrhages and 
petechise. The lungs may show atelectatic areas or may be the 
seat of bronchopneumonia. The heart is small and the muscle- 
fibre pale. In many cases the stomach is dilated and the mucous 
membrane pale. The small intestine shows few changes. The 
Peyer's patches may be slightly raised and show the so-called shaven- 
beard appearance. The follicles of the colon may be slightly prom- 
inent. The microscopical changes in the gut are not characteristic. 
In some places the follicles are the seat of catarrhal inflammation. 
Both in the stomach and the intestines there are patches where there 
is an absence of glandular tissue ; in its place is a newly formed 
connective tissue composed of round and spindle-shaped cells. The 
villi of the gut have disappeared. The whole mucosa is thinner 
than is normal (Baginsky). On the other hand, these changes may 
not be marked. The liver is fatty and may be enlarged. The 
spleen is small. The kidneys may be pale, especially in the cortex, 
and may be the seat of parenchymatous degeneration. The lymph- 
nodes of the mesentery may be enlarged. 

Symptoms. — Cases of gastro-intestinal atrophy are seen among 
the better classes, but, as a rule, they form a large contingent of 
dispensary cases exposed to unhygienic surroundings, and often im- 
properly fed. The infant may have been small at birth or prema- 
turely born. In some cases, especially in families in good circum- 
stances, the baby may have been put at the breast and have done 
well up to the time when, for some reason, it was put on condensed 
milk or milk which had been carefully modified. In other cases the 
infant may from the outset have been fed on the bottle with good 
results up to a certain point, when the weight became stationary and 
the infant retrograded and showed signs of atrophy. The atrophic 
course having once begun, the symptoms vary little. There is no 
gain in weight. The skin, especially about the inner parts of the 
thighs, becomes wrinkled, and the subcutaneous adipose tissue 
diminishes in amount. The extremities lose their normal plump- 
ness. The face has a pinched appearance. The chest is emaciated 
and the ribs show plainly. The fontanelles, if still open, may be 
somewhat depressed. Over the buccinator muscles is seen a small 
cushion of fat, the so-called " sucking pads,'' which remains when 
all the other fat has disappeared. This gives to the face a peculiar 
appearance that is typical of cases of atrophy. If the infant is not 
well taken care of, erosions and aphthae are seen on the mucous mem- 
brane of the mouth and gums, and there may also be sprue. Even 
in well-cared-for infants the buttocks may be slightly eroded. If 
the infant has been neglected, there is marked intertrigo. The but- 
tocks are emaciated and the tuber ischii show prominently. During 



INFANTILE ATROPHY. 481 

the progressive emaciation the infants have constant gastro-enteric 
disturbances. There are colic and at times constipation, or diarrhoeal 
movements alternating with constipation. The movements of the 
same infant vary greatly. They may be greenish with white curds, 
are sometimes exceedingly offensive, and at other times may be 
normal and alternate with slightly diarrhoeal movements. The tem- 
perature is normal or slightly subnormal. During exacerbations of 
the intestinal disturbances, it may rise slightly. These disturbances 
of the gut do not seem to be influenced by changes in the diet. The 
infants in many cases finally lose all desire for food. Others drink 
with avidity, but do not assimilate the food taken. If untreated, 
these infants emaciate until they are reduced to skin and bone. 
They grow exceedingly weak, and die with some intercurrent infec- 
tion, such as pneumonia, tuberculosis, or infectious disease. 

Treatment. — If an infant suffering with chronic atrophy comes 
under treatment at from the third to the fifth month, the proper pro- 
cedure is to place it on good breast milk. If this is not feasible and 
the bottle is the only resort, the task is more difficult. In rare cases 
carefully modified cows' milk (with the formula of proteids, 1.2 ; 
fat, 2.5 ; sugar, 6) will give the desired results if the infant has 
not previously had a correct diet, but has been given a proprietary 
food or a condensed milk formula. In my experience in ambulatory 
cases, no milk formulae of any kind have been universally success- 
ful. I have found that many of these cases if put on a gruel and 
milk diet, according to the method described by Keller, and detailed 
elsewhere in this work, do well : the weight increases, the colic dis- 
appears, and the character of the stools improves. After the weight 
reaches a certain point the milk gruel is discontinued and the infants 
continue to do well on an ordinary milk formula. In certain cases 
of marantic infants of the age of twelve months this method has 
been very successful, especially with those whose distaste for the 
ordinary milk foods gradually increased. It is necessary to study 
out the method of feeding which seems likely to be best adapted to 
the individual case. Greater success can be attained in private prac- 
tice than in hospitals. With the feeding, the general hygiene of the 
infant should receive attention. Daily baths with sea-salt and open- 
air life are especially indicated. 

In infantile atrophy the medical and mechanical treatment are of 
less importance than the selection of proper food. For this reason 
we should not seek to multiply remedies. The movements of the 
bowels in some cases have an exceedingly fetid odor. The treatment 
is begun with the administration of brisk cathartics, such as castor 
oil. The bowel is then washed out once a day in the same manner 
as in gastro-enteritis until the character of the movements has 
improved. If there is a tendency to diarrhoea, tannigen, with or 

31 



482 DISEASES OF THE DIGESTIVE SYSTEM. 

without bismuth, may be given three or four times daily. If 
there is any great amount of gas generated in the stomach, a very 
small dose of dilute hydrochloric acid and pepsin should be given 
daily after a feeding. 

Acute and Subacute Enterocolitis. 

{Enteritis Follicularis ; Enteric Catarrh.) 

Enterocolitis is peculiarly a diarrhoeal disease of infancy and 
early childhood. It was formerly classified as a form of dysentery, 
because in these cases the movements are tinged with blood and con- 
tain mucus. The cases are, however, really of a milder type, and 
present many symptoms foreign to true dysentery. 

Etiology. — In many of its features this affection resembles 
acute and subacute gastro-enteritis. It is prevalent during the sum- 
mer months. It occurs in infants after the first year of life, and may 
be primary or follow an ordinary dyspeptic diarrhoea, an exanthema, 
pertussis, or bronchopneumonia. Booker has described the great 
number of streptococci found in certain of these cases. Finkelstein 
and Escherich and his pupils have confirmed these results, and have 
in addition presented the view that these diarrhoeas are infectious, and 
may be caused by bacteria of the coli group. The bacteria may be 
introduced from without, or the coli organism in the gut under cer- 
tain conditions may become virulent. With reference to their origin, 
these cases may be considered as bearing a relationship to cases of 
true dysentery, from which with our present imperfect knowledge 
it is not always possible to distinguish them. 

Morbid Anatomy. — The mucous membrane is hypersemic and 
swollen ; in cases of long duration the mucosa is infiltrated with 
small round cells. The follicles of the gut are enlarged and elevated 
above the surface of the mucous membrane. The Peyer's patches 
are enlarged and surrounded by a zone of hyperaemia. The villi 
show desquamated epithelium and infiltration of the walls with 
small round cells. The follicles are swollen, and at the surface may 
burst and present follicular ulcers. The epithelium of the gut may 
be lacking in places. 

Symptoms. — In the beginning there are fever and slight vomit- 
ing. The movements are fluid, greenish, and have a disagreeable 
odor, contain mucus, and are streaked with blood. They may number 
ten or twelve in twenty-four hours. Straining at times accompanies 
the movement. As a rule the infant is pale and prostrated. The 
character of the movements is unchanged for from a few days to 
two or three weeks, when imj^rovement begins and recovery ensues. 
On the other hand, in protracted cases the infant may develop a 
bronchopneumonia in one or both lungs, but may even then recover 



DYSENTERY, 483 

under good management. The picture thus resembles that of a mild 
dysentery, but the subjects are younger, and there is in a number 
of cases a history of antecedent intestinal disturbance of extensive 
duration. 

The treatment should be carried out on the same lines as in 
acute gastro-enteritis. Caution should be exercised in returning to 
a diet composed exclusively of milk. While in true dysentery in 
older children I advise the administration of milk sterilized in some 
form, in younger infants such a procedure would be unwise. I 
keep these infants on a diet devoid of milk, such as beef-juice and 
barley-water, albumin-water or solution of acorn-cocoa, as long as 
possible. As the character of the movements improves the infants 
are put on a dilution of albumin- water and milk or cocoa and 
milk, or, what is far preferable, dextrinized gruel and milk. The 
amount of milk in the dextrinized mixture is gradually increased 
until the quantities appropriate to the age of the infant are given. 

Dysentery. 

{Ileocolitis; Oolitis Contagiosa; Coli Colitis; Enteritis Folliculari^ ; Enterocolitis.) 

Dysentery is an acute infectious diarrhoeal affection of the 
intestine. In the United States it occurs both sporadically and in 
localized epidemics. It is endemic in the tropics, where the etiology 
is somewhat different from that in our climate. The protozoon in- 
fection (amoebic) seems, according to Kartullis, to be characteristic 
of the tropical form. Although amoebic dysentery is occasionally 
seen here sporadically and in cases of persons recently returned from 
the tropics, it is not the form which commonly occurs in infants and 
children. The form to which these patients are liable is seen during 
July, August, and September, and late in the autumn. It may affect 
nurslings who are fed artificially, but most often occurs in children 
who are on a mixed diet. Escherich has described epidemics of 
limited character in private families and hospitals. I have met this 
form of dysentery in sporadic cases or small local outbreaks, and 
have also seen outbreaks at seaside resorts among children of from 
two to four years of age who had partaken of drinking-water which 
had been rendered unfit for use by contamination. 

Etiology. — The essential cause of dysentery or ileocolitis is now 
recognized to be bacterial. It is due in certain cases to the intro- 
duction of bacteria of the coli group into the gut from without 
(Escherich). Maggiora, Celli, and others have described coli bacteria 
in the stools in epidemic dysentery. These authors have shown 
that these bacilli, which resemble the Bacterium coli of Escherich, 
may cause hemorrhagic colitis in lower animals. French writers 
think that the coli group existent in the gut may under abnormal 



484 DISEASES OF THE DIGESTIVE SYSTEM. 

conditions of intestinal disturbance assume a virulence not normal 
to them. Escherich, on the other hand, has endeavored to show 
that bacteria of the coli group, if introduced into the gut from 
without, either in the drinking-water or in food, may become very 
virulent. 

Shiga, in 1897 and 1898, isolated a bacillus from the faeces of a 
number of cases of dysentery occurring in Japan. He discovered 
also that the blood-serum of the persons afflicted caused a clumping 
of the bacillus isolated when mixed with cultures of the latter in the 
proper dilutions. These cases of dysentery cited by Shiga did not 
include the amoebic variety. The characteristics of the bacillus iso- 
lated from these cases closely resembled those of the bacillus of 
typhoid fever, except that it was not motile and did not agglutinate 
with the blood-serum, as in the cases of typhoid fever. 

In 1902 Duval and Bassett studied 53 cases of diarrhoea of the 
dysenteric type, and obtained cultures of the bacillus of Shiga in 42 
of the cases investigated. Since then a number of investigators 
have studied the dysenteries of children in local epidemics, and have 
substantiated the work of Duval and Bassett, inasmuch as they are 
unanimous in attributing the dysenteric diarrhoeas of infants and 
children as being due to this bacillus. The class of cases in which 
this bacillus is found is for the most part that in which the stools 
either show blood and mucus or mucus alone in considerable quanti- 
ties. This classification does not include, as at first supposed, the 
cases of ordinary summer diarrhoea due to intestinal infection. 

Morbid Anatomy. — Dysentery may affect different sections of 
the gut at the same time, the rectal or sigmoid flexure alone, the 
ascending colon, the transverse or the descending colon only. In 
rare cases the disease may pass beyond the ileocsecal valve and 
involve the lower part of the ileum. There are two forms which 
may be present separately or simultaneously in the same gut — the 
catarrhal and the necrotic form. 

In the milder catarrhal form of dysentery the mucous membrane 
is hypersemic and swollen, and the summits of the intestinal folds 
are studded with hemorrhages in small foci or streaks. The sub- 
mucosa is infiltrated with small round cells and the vessels filled with 
blood. The epithelium of the follicles is swollen and proliferated, 
and there is infiltration of the surrounding connective tissue with 
round cells. In severe forms the surface of the mucous membrane 
is covered with mucus containing leucocytes and blood-cells. The 
follicles are elevated above the surface. In other cases the intestine 
is studded with ulcerations which mark the necrotic follicles. The 
ulcerations reach to the muscularis mucosae. If the process extends 
to the small gut, the Peyer's patches are swollen and surrounded by 
a hypersemic zone. 



DYSENTERY. 



485 



If the disease has advanced to the necrotic stage, the mucosa is 
thickened and infiltrated with round cells. There are areas of loss 
of tissue which extend deep to the muscular coat (gangrene). The 
mucous membrane is covered with a grayish exudate of a pseudo- 
membranous character. In severe cases large areas of the mucous 
membrane may necrose and be cast off. The necrotic areas show 
an abundant invasion of bacteria of the coli type, in scattered masses 
or zoogloea. The lymph-nodes of the mesentery are swollen ; the 
spleen may be enlarged ; the kidneys may show degenerative 
changes, and the lungs may be the seat of bronchopneumonia. 

The symptoms of dysentery in infants and children closely re- 
semble those seen in the adult subject. The onset may follow some 
indiscretion of diet or be entirely independent of any such error. 
There may be a preceding headache, and there is, as a rule, some 
fever. Abdominal pain is the first symptom until diarrhoea sets in. 
The diarrhoea at first resembles an ordinary dyspeptic diarrhoea, but 
in a few hours or after one or two movements, it assumes the charac- 
teristics which mark it as specific. The patient passes stools which 
are fluid and contain mucus mixed with blood and shreds of tissue, 
and which may have an offensive odor. They are passed with much 
abdominal pain and rectal tenesmus. If the abdominal pain is 
severe, there are vomiting and great prostration. As many as twenty 



Fig. 97. 


iuneYs 1 2 a 4 5 6 7 


HOUR 369 12 369 12 369 12 369 12 369 12 369 12 369 12 36 9 12 38a 12 369 12 369 12 369 12 369 12 3169 Il2 

102^ 1 1 ^ 

|'"°EEEEEEE?-^7EEtEEEE^?J!jEEEj5=i?EEEEEEEEEEEEEEEEEEEEEE 


PULSE iS§iili222il 2§SSSi gS 1S2S S§SsJs8 S i 2 2 SMISII 


RESP. SSSSS8SSSSSSS sss:s;ss ss; sssis; sssssi^s ^ss;^^ sas^ss 


URINE XXX X XXX. X XXXXXXXX X XXX |x XX 


STOOL II 1 1 1 1 1 1 1 1 II 1 11 1 III 1 II II II II II II 1 II II 1 II 1 1 II 1 1 1 1 III II 


WEIGHT 52 BS. 



Dysentery of ordinary severity. First week of illness. Duration three weeks; recovery- 

Boy, seven years of age. 



to thirty small bloody mucoid movements may be passed daily. The 
fever varies in intensity. In mild cases the temperature may range 
from 101° to 102° F. (38° to 38.5° C.) (Fig. 97); in severe 
ones it may reach 104° (40° C.) (Fig. 98). If the disease persists 
beyond a few days, there is rapid emaciation and the abdomen 
becomes sunken and board-like. In some cases palpation in the 



486 



DISEASES OF THE DIGESTIVE SYSTEM. 



region of the caecum and ascending colon may detect the contracted, 
thickened gut. In one case of the necrotic type, I could during life 
mark out the caecum and ascending colon as a contracted, thickened 
tube. In protracted cases the spleen becomes enlarged and the 
tongue dry and coated, in this respect resembling the condition seen 
in typhoid fever. Multiple hemorrhages may appear under the skin. 
The urine contains albumin, and in some cases hyaline and epithelial 
casts. 

Course. — The fulminating cases run their course in a few days 
with high fever, terminating in death. Other cases may be com- 
paratively mild and last only a few days or a week. In such cases 
there may be recurrences. In other cases the disease runs a course of 
from three to six weeks. After this period, from time to time, blood, 
evidently derived from bleeding ulcers in process of repair, may 

Fig. 98. 



lUNEss 4 5 C 7 8 10 


HOUR 3 6 9 12 3 6 9 12 3 6 9 12 3 6 9 12 3 6 9 12 3 6 9 12 3 9 12 3 6 9 12 3 6 9 12 3 6 9 12 3 6 9 12 3 9 12 3 6 9 12 3 6 9 12 










106° '' 














T 


t 










-^ -^ J 


tc -^ -- -t 




















c 2_^ =L-i ^---f ^^r.^^ A-' 


101 f__ jL_ J ±--~ t-V--V---^-v3-- 


/V/\ \ A \ \A \ 




o %^t---^-A — -^r^- £^ =iE 


100 rV W^----i S tt 




i^ 1 


c 7 


qq 4 












PULSE ISSiSiz ^SSiSSSSSsIS SISr2S2si§2i s^sf^gs 


RESP. S2SS5S33 SS5?SSg3!55S=;3 SS5gS3SS3SSSSSS???S?5 


URIHE XXXXXXXXXXXXXX3XXX22XXXXXXXXXXX XXX X X XX 


STOOL 1 1 1 1 1 1 1 II II II 1 II 1 ir II 1 1 I 1 


WEIGHT 28 LbL 8 OZ. 



Necrotic colitis ; fatal, in a girl six years of age. 



appear in the movements. The movements gradually become formed 
and fecal in character, and the patient recovers. In cases which 
have come under my care in hospital service, the disease ran a moder- 
ately severe course until the seventh or eighth day. The fever, how- 
ever, remained high and delirium set in on the ninth day. The 
appearance of the patient becomes septic, sopor supervened, and the 



DYSENTERY. 487 

urine and feces were passed involuntarily. Death took place on the 
thirteenth day. In other cases of a severe necrotic type death took 
place at the end of a week. 

Complications. — The most dangerous complication is perforation 
and general peritonitis. Periproctitic abscess may occur, with sub- 
sequent fistula. In septic cases, abscess of the liver and spleen have 
been observed. Hemorrhages may occur under the skin late in the 
disease. In all of my cases these were quite extensive, but recovery 
nevertheless took place. In one fatal case I noted metastatic paroti- 
tis. Some authors have recorded arthritis as a complication ; as a 
rule it retrogrades and recovery takes place. 

The prognosis varies with the severity of the case. The mor- 
tality ranges from 30 to 40 per cent. The croupous or necrotic 
cases are very fatal. With good management the mild cases give 
a favorable prognosis. The severity of the infection and the 
prevalence of an epidemic will influence the course of the affec- 
tion. 

Treatment. — Prophylaxis. — The movements are not only infec- 
tious, but may also communicate the disease to others if a particle 
is introduced into the gut. The hands of the patient and his 
body should be kept scrupulously clean to avoid reinfection. The 
movements should be disinfected in the same manner as those of 
a patient suffering with typhoid fever. The hands of the nurse 
should be scrupulously cleansed and washed in an antiseptic solu- 
tion. 

The patient is given a cathartic, preferably castor oil, as the initial 
step of treatment. In this way all irritating food particles and 
residual feces are cleared from the gut. All food, ev^en milk, is with- 
held at first. The patient for the first twenty-four hours is given a 
solution of egg-albumin, acorn -cocoa, beef-juice broths, or expressed 
beef-juice and barley-water in equal parts. The following are the 
lines along which the later management of these cases should 
proceed : 

a. An absolutely non-irritating and easily assimilable food is 
given. 

h. The pain and tenderness are relieved with drugs, the diarrhoea 
being also partially controlled in this manner. 

c. The rectum is irrigated. 

d. After a day or two, during which the patient has been fed 
upon albumin-water, expressed beef-juice, and barley-water or acorn- 
cocoa solutions, sterilized or pasteurized milk is substituted. In 
these cases, as in typhoid fever, the patients arc given during twenty- 
four hours, two or more quarts of milk sterilized at 212° F. (100° C.) 
or pasteurized at 164° F. (73° C). I wait until the severely acute 
symptoms have subsided before placing these patients on a milk diet. 



488 DISEASES OF THE DIGESTIVE SYSTEM. 

At best, milk leaves a large residue in the gut, and in the acute stage 
of the disease the coagulum may in a mechanical way irritate the 
acutely inflamed walls. Pasteurized and sterilized milk is well 
borne in the later stages of the aifection. Milk in a raw state, no 
matter how good, will sometimes tend to aggravate the acute symp- 
toms. Pain and tenesmus are relieved by the exhibition of Dover\s 
powder, grains J to ij (0.03 to 0.12), every two hours according to 
the age of the infant or child. Codeine sulphate, grain i to \ (0.01 
to 0.015), according to the age of the patient, is preferable to mor- 
phine or tincture of opium. The administration of powdered ipecac- 
uanha will be found very useful in certain cases. In others the 
vomiting rather interferes with its administration ; grains j to ij or 
iij (0.06 to 0.12 or 0.2) every two or three hours are indicated. It 
may be combined with bismuth subcarbonate, grain v (0.3) every 
three hours. 

In older children this mode of treatment has lately given good 
results. I have had no experience with the administration of lead 
salts. In the acute cases the internal administration of prepara- 
tions, such as tannigen, is irritating. 

Rectal enemata should be employed with care in the treatment of 
colitis or dysentery. Unless caution is exercised, their use is in 
many cases followed by an exacerbation or perpetuation of symp- 
toms. The most useful form of enema is the warm (108°-110° F., 
42.2°-43.3° C.) saline (Cantani) solution. Fully a quart of fluid 
is allowed to flow into the gut. The greater part of it returns, but 
I believe that if a portion of this solution is retained it acts in the 
manner of enteroclysis and supports the patient. These enemata are 
given three times in the twenty-four hours, for a day or two ; they 
are subsequently given twice a day, and finally, as the symptoms sub- 
side, only once a day. I have never been able to convince myself that 
silver nitrate (1 : 1000) or tannic acid added to the enemata is of 
value. On the contrary, I believe that in cases in the acute stage 
these medicated enemata are distinctly irritating. In the later 
stages of the disease, small quantities of fluid blood are passed with 
the fecal movements, tenesmus being present ; small enemata of 
silver nitrate (1 : 1000) given low down twice daily cause cessation 
of the bleeding which is due to the presence of ulcers low down in 
the rectum. In the subacute stage, the enemata will often be fol- 
lowed by an exacerbation of bloody mucous passages. Under these 
conditions it is well to discontinue the enemata and to watch the 
results of the suspension of local treatment. 



CONSTIPATION IN INFANTS AND CHILDREN. 489 

AmcBbic Dysentery. 

Amoebic dysentery is not, strictly speaking, a disease of infancy 
and childhood. It is caused by the Amoebae coli of Losch. Of 
35 cases reported by Harris, 4 were under ten years of age. Amberg 
has recently published 5 additional cases. The etiological factor is 
the Amoebae coli, which are found in large numbers in the movements. 
With the amoeba, Charcot-Leyden crystals are found in most cases. 
The cases published by Amberg were of a mild type, and seemed in 
no way to differ in symptomatology from the form of the disease 
seen in the adult subject. There were diarrhoea of a bloody character, 
tenesmus, and in some cases fever and prostration. As many as from 
four to six movements containing blood and mucus, and microscopi- 
cally eosinophile cells, were passed in twenty-four hours. 

The diagnosis is made from the presence of the amoebae in the 
movements. Bloody passages containing Charcot-Leyden crystals 
should cause the physician to entertain a suspicion of the presence 
of this affection. 

Other amoebae, such as the Monocercomonas hominis (Grassi), have 
been found in the movements of infants suffering from diarrhoea. 
Epstein describes an epidemic of diarrhoea in which the monocer- 
comonas abounded in the movements. He thinks that in this epi- 
demic the diarrhoea Avas caused by well-water which contained the 
amoebae. I have found the Monocercomonas hominis in the move- 
ments of infants who were suffering from diarrhoea, but also of those 
whose bowels w^ere not in an abnormal condition. The role of the 
monocercomonas as an etiological factor in the causation of these 
diarrhoeas is not understood. It is doubtful whether they have any 
causal connection with the diarrhoea. 



Constipation in Infants and Children. 

Constipation may be classified as congenital and acquired. 

Congenital constipation is noticed immediately after birth, or 
in the days subsequent to it. The causes of congenital constipation 
are generally an absence of the anus or its occlusion by a thin mem- 
brane, or by a thick, hard membrane resembling the skin ; or there 
may be an anus and a shallow or deep cul-de-sac leading from the 
anus for some distance into the rectum, or this may be occluded at a 
varying distance from the external orifice. The rectum may be 
occluded by one or several membranes. Its walls may be thick- 
ened, so that meconium or faeces cannot pass ; or its walls may be 
agglutinated. The rectum, as has been stated, may end at some 
distance from the anus in a blind cul-de-sac, and from this point 
upward the rectum may either exist in its normal calibre, or may be 



490 DISEASES OF THE DIGESTIVE SYSTEM. 

simply indicated by a fibrous cord ; in other words^ there may be a 
congenital absence of the rectum. The rectum may end in a pre- 
ternatural opening into the bladder, the urethra or vagina, or may, 
by a common opening, a sort of cloaca, terminate in the perineum 
through the urethra or vagina. In such cases there is scarcely con- 
stipation, but rather a difficulty in voiding the fseces. There may 
be, as has been intimated, partial or complete absence of the rectum 
or colon ; or a large part of the larger bowel may be absent, or it 
may be stenosed in part of its extent and dilated in another part. 
It may be abnormally contracted. The colon or any part of it may 
be rudimentary. There may be obstruction, as in the rectum, in 
any part of the course of the colon. There may be a congenital 
occlusion of the ileocsecal valve. 

Finally, Jacobi has placed on record a case of congenital consti- 
pation due to misplacement of the large gut and inordinate dilata- 
tion of this viscus. In some cases of congenital malformation the 
small intestine may be entirely obliterated ; or the small intestine in 
part of its extent may be normal, especially the duodenum ; whereas 
the ileum may be rudimentary and the large gut enormously dilated. 
There are cases on record in which there was no connection between 
the large and the suiall intestine, and there may be congenital stric- 
ture in any part of the small intestine, either the duodenum or the 
ileum ; or there may be an obstruction due to a small diaphragm ex- 
tending into the lumen of the gut in any part of its course. It may 
be seen from a simple enumeration of the causes of congenital con- 
stipation that the conditions found are extremely varied, and in most 
cases cannot be remedied by surgical means unless the obstruction 
diagnosed is low down in the rectum or sigmoid flexure, and 
exists without any accompanying deformity of the rest of the gut. 
A congenital absence or rudimentary condition of the small or large 
gut must eventually prove fatal. The symptoms of all the cases 
recorded of congenital constipation are those of obstruction, in the 
end resulting in rejection of all fluids, vomiting, and ending fatally 
if unrelieved. A further discussion of this form of constipation is 
scarcely within the scope of this treatise. 

Acquired constipation may be acute or chronic. Acute consti- 
pation is really a surgical disease, and is caused in infants and chil- 
dren by some acute obstruction of the gut, such as intussusception, 
volvulus, strangulation, through a slit in the omentum, strangulation 
by peritonitic bands, or by the persistence of Meckel's diverticulum ; 
hernia of all kinds, strangulation or paralysis of the intestine as a 
result of traumatism. Peritonitis may cause acute constipation, and 
with this we must consider diseases such as appendicitis. 

Foreign bodies may obstruct the lumen of the bowel. Watkins 
has recorded in the Lancet the case of a boy, ten years of age, who 



CONSTIPATION IN INFANTS AND CHILDREN. 491 

had swallowed an immense quantity of figs, which obstructed the 
lower part of the gut near the anus, and had to be removed by sur- 
gical means before movements were established. J. Lewis Smith 
relates the case of a girl, four years old, in whom acute constipation 
developed suddenly as the result of the impaction of a mass of in- 
tertwined worms in the gut. This acute obstruction was attended 
by distention of the abdomen and great suffering. A large gall- 
stone is mentioned as obstructing the ileocsecal valve, and in this way 
suspending for a time the passage of fseces through this structure. 

The diagnosis of acute constipation presupposes a diagnosis of 
the primary causal condition, and this can only be made by a care- 
ful study of the case. Cases of intussusception, volvulus, strangu- 
lation of the gut, either by bands or hernia or forms of peritonitis, 
will give symptoms of these diseases. It is scarcely the place here 
to enter upon these fully. In those cases in which worms obstruct 
the gut, the diagnosis can only be made after relief has been estab- 
lished by passage of the corpus delictu, unless enough faeces are 
voided to examine the same for eggs of the worms. 

Chronic constipation may be dependent upon obstruction of the 
large or small gut in any part of its extent, either by morbid growths, 
sarcomata, carcinomata, or tuberculous peritonitis. The latter form 
of obstruction of the gut by tuberculous masses is of especial inter- 
est, inasmuch as these cases form a part of the symptomatology of 
tuberculous peritonitis. I saw recently a case of tuberculous peri- 
tonitis in which large masses were palpable in the abdomen, and in 
which one of these masses involved the descending colon to such an 
extent as to almost completely occlude its lumen. 

Anal fissure is a common cause of chronic constipation in infants 
and children. In these cases there is always a history of great pain 
when the movement is passed, and for some time afterward. Blood 
may accompany movements when there is a fissure of the anus. 
Children suffering in this manner do not void a movement for days, 
and when the movement is passed the suffering sometimes is intense. 
In some children there is a spasm of the anus due to a nervous con- 
dition, and sometimes brought about by an excoriated state of the 
anus. Examination does not reveal any fissure, but there is a dis- 
tinct spasm of the sphincter which prevents the successful evacua- 
tion of the rectum. In all of these cases chronic constipation is 
really a surgical disease, and can only be relieved by surgical meas- 
ures. In some cases caused by cancerous, sarcomatous, or tubercu- 
lous growths even the surgeon is helpless to relieve the patient. 
Constipation caused by anal fissure, spasms of the sphincter, or ex- 
coriations around the anus yields more successfully to surgical treat- 
ment, which is the same as a treatment for similar conditions in the 
adult, viz., forcible dilatation of the sphincter. 



492 DISEASES OF THE DIGESTIVE SYSTEM. 

Chronic Habitual Constipation. — The next form of chronic 
constipation which we will consider is that which most interests the 
general practitioner, and is known as chronic habitual constipation. 
Of all the conditions within the domain of pediatrics habitual con- 
stipation is the most difficult of management. It is not always 
possible in these infants and children to fix on the absolute causes 
of a constipated habit. 

Breast-fed Infants. — Infants at the breast may be constipated 
from birth, though normal in every other respect, and continue 
this habit throughout childhood. In many of these cases the 
mother is of a constipated habit. Some signs of rachitis may be 
present in certain cases. In these cases, however, it is reasonable 
to conclude that the mother's milk is lacking in some element, such 
as fat, which tends to perpetuate the constipation. In other cases 
the milk may be absolutely normal, and still a condition of atony 
of the gut of an hereditary type may exist. 

Constitutional Dyscrasia. — Rachitis, when marked, is associated 
with constipation in a large proportion of cases. In a manner simi- 
lar to the bones, so the muscular apparatus lacks tone, and it is not 
surprising that with the muscular atony the glandular elements 
of the gut should be deficient in furnishing elements necessary to a 
normal maintenance of the functions of the gut and evacuation of 
the intestinal contents. 

Heredity has been named as a cause of constipation in breast-fed 
infants, and it is not infrequent to meet the same condition, possibly 
due to the same cause, in bottle-fed infants. Incorrect feeding is 
certainly one of the most frequent causes of constipation in artifi- 
cially fed infants and children. Some infants who have been started 
on very dilute modifications of milk are constipated from the begin- 
ning, or their constipation has been fostered by heating the milk to 
a greater or less degree, and in these cases the constipation, if allowed 
to persist for any length of time, is perpetuated into the period of 
childhood. In older children a simple diet of two or three articles 
of food, which have been religiously adhered to from the time of 
weaning to a varying period of childhood, is the direct cause of con- 
stipation. There has been a failure in these cases to give an appro- 
priately mixed diet. I have seen constipated children, at varying 
periods of childhood, who have been kept systematically on a diet of 
milk and fruits, for fear that any other article of diet w^ould cause 
intestinal disturbance. The result has been an inordinate constipa- 
tion, of chronic duration with accompanying symptoms. 

Symptoms. — One can scarcely speak of the symptoms of a condi- 
tion which in itself is a symptom of disturbed conditions. There 
are certain features, however, of the movements of constipated in- 
fants and children which are of importance. 



CONSTIPATION IN INFANTS AND CHILDREN 493 

The movements of infants suffering from constipation may be 
hard and formed, or may be unformed and dry. Ordinarily a healthy 
infant has two, three, or four movements daily, the rule being two. 
A healthy infant may have six movements a day and still be within 
the limits of health. We judge by the character rather than by the 
number of the movements. The movements of infants and their 
normal characteristics have been dilated upon elsewhere, and the 
reader is referred to the section treating of this subject. 

In constipated infants the movements consist almost entirely of 
marble-like masses, resembling those seen in the lower animals. 
They rarely have a movement unaided. They have great pain in 
passing the movements, and in time develop fissuration of the anus 
to a greater or less extent, with accompanying bleeding due to the 
stretching of the fissure. In other cases this bleeding is accom- 
panied by slight prolapsus of the gut during the movement, which 
often creates the impression that the infant is suffering from hemor- 
rhoids. Many of these constipated movements are coated with 
mucus, or mucus is voided after the movement is passed. These 
masses are not membranous, and if examined will be seen to be 
composed mostly of mucus. Constipated infants after a time develop 
a pallor and ansemia which is characteristic, and seem to suffer from 
intestinal absorption and toxaemia which results from time to time 
in periodical attacks of vomiting, which is discussed elsewhere. 
These children also complain from time to time of a vertigo and 
nausea, especially in the morning. Many children who are thus 
constipated will reject their food in the morning. They lose their 
appetite and have all the symptoms of intestinal intoxication. 

The treatment of constipation is dietetic and medicinal. If the 
infants who are constipated are fed at the mother^s or nurse's breast, 
the bowels of the mother or nurse need regulating, and they should 
take regular exercise. In many cases a nutritious diet to the mother 
or nurse will cause the milk to change in its composition, contain- 
ing more fat, and thus improve the condition in the infant. This is 
not always the case, however, and the most baffling cases of consti- 
pation are those which exist in infants at the breast. It has been 
suggested by Biedert and Holt to give such infants a small quan- 
tity of cream after each feeding ; but even this procedure does not 
succeed in many cases, and in the summer is distinctly dangerous, 
inasmuch as the mixed feeding may disagree with the infant. A 
teaspoonful of cream containing 16 per cent, of fat, or a teaspoonful 
of the nine-ounce top milk taken from a quart of milk is given three 
or four times daily before or after nursing, and in some exceptional 
cases the bowels can be regulated. As has been intimated, some 
infants on this treatment begin to vomit and develop a diarrhoea, 
especially in the summer season. This diarrhoea is not necessarily 



494 DISEASES OF THE DIGESTIVE SYSTEM. 

an infectious one, but is rather a fat-diarrhoea, and is as difficult to 
control as some of the infectious varieties. It is scarcely advisable 
to pursue this method of treatment during the summer season. If 
artificially fed children are constipated, the heating of the milk should 
be stopped. If for some reason milk must be pasteurized or steril- 
ized, the time of heating should be reduced to a minimum. Consti- 
pated infants may be fed on raw milk if the milk is fresh and care- 
fully kept. The formula should contain sufficient fat to make the 
diet nutritious, but the fat should not form more than 4 per cent, of 
the mixture. As a rule, artificially fed infants do well on a smaller 
quantity of fat than the average breast-fed infant. Thus 2.5 to 3 
per cent, of fat meet the requirements of most infants. If they are 
constipated the fats are raised to 4 per cent. This proportion should 
not be increased, since there is danger of disturbing the functions of 
the gut to such an extent as to give rise to conditions more serious 
than the constipation. 

Children from the sixteenth month to the second year who suffer 
from constipation should be gradually weaned to a mixed diet. In 
many cases this procedure will regulate the bowels. The children 
should be given green vegetables, such as peas and spinach, in the 
form of a puree. The diet should include cereals of the various 
varieties, especially wheatena, oatmeal, granum, and rusk (Zwieback). 
The milk should be given raw with a moderate mixture of cream. 
Fruit, such as oranges, raw apples, and pears, is also given in moder- 
ation. If the constipation cannot be remedied by these measures, 
recourse is had to medicinal treatment. 

Cathartics. — At best, cathartics are a makeshift. Some older 
children will do well with a small dose, grain y^^ (0.0004), of 
strychnine once a day, and a simple cathartic, such as the aromatic 
fluid extract of cascara, twice or three times a week. A child two 
years of age may be given 1TL xx to xxx (1.0 to 2.0) once a day. 
The preparations of rhubarb are useful, but do not give uniformly 
satisfactory results. The mercurial cathartics are available only once 
a week in the majority of cases. We are thus reduced to the neces- 
sity of giving suppositories or enemata. With very young infants a 
small cylindrical piece of soap inserted with oil into the rectum once 
a day will be effective. With older children the glycerin suppository 
given every other day is very useful. 

Enemata. — In many cases it is necessary to give enemata : to 
younger infants they are given once a day ; to older children affected 
with the form of constipation occurring in connection with mucous 
colitis, an enema is given twice a week. The diet in these cases of 
mucous colitis should be regulated. When the child becomes pale 
and listless a brisk cathartic aided by a large high enema is given. 
In this way the attack of vomiting may be avoided. 



CONGENITAL DILATATION OF THE COLON. 495 

Massage. — Massage of the abdomen gives very unsatisfactory 
results. Gymnastics or calisthenic exercises in the morning after a 
bath are useful in some cases. 

Useful formulae are the following : 

1. Pulv. glycyrrhizse comp. . . ^ss to 3j (2.0 to 4.0) as necessary. 

2. Infus. sennse comp 3J~3ij (4.0-8.0) as necessary. 

3. Podophyllin grij(0.12). 

Syr. rhei arom ^ij (60.0). 

Sig- 3J (4.0) pro dosi. 

Congenital Dilatation of the Colon, With or Without Hyper- 
trophy of Its Walls. 

This deformity is one of the rarer causes of habitual constipation 
in infants and children. We distinguish three forms of this condition ; 

a. In this form there is an increase in the length of the colon 
descendens and the sigmoid flexure. As a result of the increased 
length of the colon this portion of the intestine bends two or three 
times on itself. There is a stagnation of the faeces and consequent 
constipation. Toxaemia results and emaciation follows. With the 
above there are symptoms of fermentation in the gut^ and constipa- 
tion alternates with diarrhoea. The diarrhoeal movements are foul, 
containing mucus and blood. There is some meteorism. 

The prognosis of this form is not bad, provided a complicating 
colitis does not ensue. As the child grows older the above symp- 
toms improve and normal conditions ultimately supervene. 

b. In this class of cases the colon is not only lengthened and 
dilated, but its walls are thickened. Such are the cases of Mya, 
Formad, Griffith, and Hirschsprung. According to Concetti, the 
mucosa is not only thickened, but the connective tissue and muscu- 
lar coats of the intestine show the same changes, and the arteries are 
the seat of arteritis. The cases belonging to this class in the litera- 
ture range from eight to fifty years of age. It is in this set of cases 
that stagnation of the faeces is accompanied at times with ulceration 
of the gut. 

c. In this class of cases there is a combination of the dilatation 
of the colon with thin walls ; or the colon may be normal in its 
lower portion and slightly ectatic, with hypertrophied walls above. 

The symptoms of the last two sets of cases are more severe in 
the younger and milder in the older children. They are severe if 
the condition has lasted for two or three years, and milder if the 
patient has survived until the tenth or twelfth year. From the 
second to the fourth day after birth great meteorism appears. No 
meconium is passed for some time, and there is no stenosis of the 
gut ; laxatives succeed in bringing away only a small amount of 
meconium or faeces. The constipation is very obstinate, the faeces 



496 DISEASES OF THE DIGESTIVE SYSTEM. 

are foul-smelling, and from time to time colitis may supervene, or 
every eight to thirty days hard, malodorous masses are evacuated 
with slime and blood. There is a condition of an auto-intoxication 
and a resultant cachexia. The abdomen becomes enormously dis- 
tended, and the coils of the gut can be made out on the surface. 
The children die during the first and second years of life, either 
through cachexia or perforation of the gut. Of the 21 cases col- 
lected by Concetti only 2 lived. One was a case of his own, and 
another that of Osier ; in both an artificial anus was made for the 
relief of the condition. Colitis, with or without perforation of the 
gut, is the most frequent cause of death. The remaining cases die 
of cachexia. 

Treatment. — The first class of cases are treated in much the 
same manner as is constipation. In the second and third forms 
surgical interference is indicated as soon as the diagnosis is made. 
The colon is resected. Thus far surgical interference has not been 
attended with great success. 

Acute Intestinal Obstruction. 

( Intussusception. ) 

Intussusception, according to Treves, is the prolapse of one part 
of the intestine into the lumen of an immediately adjoining part. It 
causes more than one-third of all the varieties of obstruction of the 
gut. 

Varieties. — Invagination of the gut may take place in any part, 
from the duodenum to the rectum. There are the following forms : 

The enteric form, which may involve any part of the small intes- 
tine, but which most commonly involves the lower part of the 
jejunum or the ileum. 

The colic form, which may involve any portion of the colon. 

The ileocsecal, which is the most common form. 

In the ileocsecal variety the ileum and caecum pass into the colon, 
the valve preceding and forming the apex of the intussusception. In 
the ileocolic form, the valve remains stationary and the ileum passes 
into the colon. In the latter form there is an invagination of the 
caecum and colon, of a secondary character. 

Etiology. — Nothnagel demonstrated that intussusception is caused 
by irregular muscular action in the wall of the gut ; in acute intus- 
susception this is of a spasmodic character. In 50 per cent, of the 
cases little is known of the exciting cause. 

Diarrhoea, the various forms of enteritis, polypi, and diverticula, 
improper food, traumatism, and exposure to cold, have all been 
regarded as exciting causes. Typhoid fever and pertussis have been 
complicated or followed by intussusception. I have recently seen a 
case following typhoid fever in a boy three years old. 

Meckel's diverticulum and the appendix have been the cause and 



ACUTE INTESTINAL OBSTRUCTION. 497 

seat of intussusception. In the latter case the inverted appendix 
caused ileocsecal intussuception. 

Frequency. — Intussusception is more common in males than in 
females. The disproportion diminishes after the first year of life. 
Fifty per cent, of all the cases occur before the tenth year, and chiefly 
in individuals who are not in good physical condition (Treves). In 
the cases that I have seen, the infants were delicate, the child being 
robust in only one case. 

The youngest case I have met was five and a half months of age. 
This infant was breast fed, had suffered with colic, and had had 
green movements from birth ; there was an ileocsecal invagination 
eight inches in length. 

Symptoms. — The onset is sudden in 75 per cent, of the cases ; 
in the colic and rectal varieties it may be gradual. In many cases 
the disease makes its appearance while the infant is nursing or 
during sleep. The patient, being attacked with pain, suddenly 
awakes from sleep with a cry and begins to vomit ; on the same 
day or the following day a bloody movement appears, the amount of 
feces being small. In a few cases there are no fecal evacuations. If 
the case is progressive, the pain returns in paroxysms, the hemorrhagic 
movements are repeated, and the vomiting keeps pace with the in- 
crease of the obstruction. The general condition of the patient 
grows worse ; apathy and collapse ensue. I have seen cases begin 
with a mild diarrhoea ; the pain suddenly appears, and also the 
hemorrhages from the bowel, the infant at once going into collapse. 
There is apathy, from which it is difficult to rouse the patient. If 
the case continues to progress, the movements become frequent, ex- 
haustion increases, and finally death from asthenia results. The pain 
is great at the onset, usually reaches its maximum intensity within a 
short time, and then gradually subsides. It is of a paroxysmal char- 
acter and is colicky during the advance of the invagination ; as 
adhesion takes place or gangrene occurs it diminishes. The intervals 
between the paroxysms of pain are at first of considerable length ; 
later they become shorter. The pain is most severe in the ileocsecal 
form, and is in all forms caused by irregular intestinal peristalsis. 

Vomiting is not so prominent a symptom as in other forms of 
intestinal obstruction (Treves). In 75 per cent, of the cases it 
comes on early with or directly after the pain. It may not recur for 
hours. In a child taken with sudden pain of a colicky character, 
vomiting, and bloody stools, the vomiting recurred only twice within 
twenty-four hours. It is apt to be less violent as long as there is 
not complete obstruction of the gut ; in other words, it is more 
marked in those cases in which no feces pass through the gut. As 
long as the pain recurs in paroxysms (progression of the intussuscep- 
tum) the vomiting is not apt to be marked. The vomited matter is 
composed of the stomach contents and is biliary ; stercoraceous 
33 



498 DISEASES OF THE DIGESTIVE SYSTEM. 

vomiting was found late in only 25 per cent, of Leicliten stern's cases ; 
Gibson also found it to be rare and late. If stercoraceous vomiting 
was present, it appeared from the fourth to the seventh or to the 
fourteenth day. In the case referred to, in the infant of five and 
one-half months, it appeared during the first twelve hours of the 
disease. 

The condition of the bowel is important. It is generally stated 
that constipation occurs from the outset ; this is not universally true. 
Cases in which constipation exists throughout, that is to say, in 
which no feces whatever are passed, are not common, and form only 
30 per cent, of the total number. Diarrhoea is the common condition 
at the outset ; as the obstruction increases, the amount of feces in 
the stools diminishes, and finally only mucus and blood are passed. 

The most important symptom in connection with the bowels is 
hemorrhage. Hemorrhage from the bowel, in connection with pain 
and other abdominal symptoms, is considered by Gibson as pathogno- 
monic. It was present in 80 per cent, of the cases tabulated by 
Leichtenstern. As a rule it is considerable. It is said by Treves 
to have been in some cases so great as to cause death. The blood and 
feces have a cadaveric odor, which however is not always, as some 
writers affirm, a sign of gangrene. I have perceived this odor in an 
intussusception which operation showed not to be the seat of gan- 
grene. It is caused by decomposition of the blood in the gut. 

The temperature is normal, slightly subnormal, or slightly ele- 
vated. There may be a slight elevation of temperature without peri- 
tonitis. The quantity of urine may as in other forms of intestinal 
obstruction be diminished. 

Tenesmus is present in 55 per cent, of the cases ; it depends more 
or less on the presence of the intussusception in the rectum. It is 
usually an early symptom in the rectal form, and is more common 
in the ileocsecal variety than in the enteric. 

The abdomen is not at first distended ; it may, on the contrary, 
be retracted ; if tympanites occurs at all, it does so late and in the 
presence of a general peritonitis. Palpation of the abdomen is at 
first well borne, but after a time there is sensitiveness. 

A tumor felt through the abdominal wall or in the rectum is of 
the greatest value in the diagnosis. It cannot be felt if the intus- 
susception is in the hepatic or splenic flexure of the colon. It is 
variable in distinctness, and is most frequently felt in the region of the 
descending colon or of the sigmoid flexure. It is hard and resistant, 
and rarely more than six inches long. It is often said to be sausage- 
shaped, but the statement is misleading. The tumor is rarely felt in 
the ileocsecal region, for the reason that the intussusception in this 
locality is small, and is that of a small gut inside of a large one. In 
one-third of the cases the rectum, if examined, shows the presence of 
the intussusceptum. The rectal tumor is commonly found in children. 



ACUTE INTESTINAL OBSTRUCTION. 499 

because in them the colon is mobile. The gut may reach the anus 
as early as the second day, the average time being the seventh day. 
It may protrude from the anus from three to eight inches, and may 
be in a gangrenous state ; under these conditions it has been mis- 
taken for a polypus or hemorrhoid. 

Prognosis. — As regards duration, there are three varieties of 
intussusception — the ultra acute, the acute, and the subacute. The 
ultra acute cases are exceedingly rare. Leichtenstern found only 
5 of this form in a total of 7269 cases ; 4 of the 5 occurred in 
infants less than a year old. All were fatal. 

The rate of mortality in intussusception, excluding the ultra 
acute forms, varies as given in the statements of different authors. 
Gibson^s statistics place the mortality at 53 per cent. It varies 
with the age of the patient, the duration of the disease before 
operating, and the success in reducing the intussusception. In- 
tussusception is extremely fatal in infants under the first year. 
Thus according to Treves, the mortality under one year of age is 80 
per cent. On the other hand, if we study the cases as Gibson has done, 
we find that the cases operated on during the first day of the dis- 
ease had a mortality of 41 per cent.; those on the fourth day, 72 
per cent. The reducible cases showed a mortality of 38 per cent.; 
the irreducible, of 88 per cent. 

Diagnosis. — From the studies made by Gibson, it may be seen 
that, in children, a bloody discharge with abdominal pain of a 
paroxysmal nature is almost pathognomonic of intussusception. 
The presence of a tumor fixes the diagnosis absolutely. Fecal 
vomiting is of very little value as a diagnostic sign. It is very 
infrequent, and is in any case present only late in the disease, 
when occlusion of the gut has occurred. If enteritis exists in a 
young infant, it is often difficult in the absence of any abdominal 
or rectal tumor to make a diagnosis. The course of the case will 
guide the physician. In dysentery the hemorrhage from the bowel 
is not great ; it is composed of blood-tinged mucus. Cases of scurvy 
may simulate intussusception if bloody discharges appear with the 
intestinal movements. In these cases the amount of blood voided 
per rectum is fully as great as in cases of intussusception. In scurvy, 
however, there is faecal matter in the movements, in the cases coming 
under observation of the author, as also signs of scurvy, such as ten- 
derness of the bones and spongy, bleeding gums. Appendicitis 
has been mistaken for intussusception. It frequently occurs with 
it, and thus obscures the picture. Peritonitis can hardly be mis- 
taken for intussusception. In peritonitis the pain is continuous 
and there is tympanites, but no bloody discharge. Tuberculous 
peritonitis is sometimes mistaken for intussusception. In tubercu- 
lous peritonitis the symptoms are not progressive, and also there is 
not likely to be a bloody discharge. 



500 DISEASES OF THE DIGESTIVE SYSTEM. 

The case following typhoid fever, to which I referred, simulated 
a hemorrhage from a typhoidal ulcer. A careful examination under 
an anaesthetic cleared up the case. In complete relaxation under 
anaesthesia, a tumor could be felt in the caecal region of the ascend- 
ing colon. The result of examination was verified by operation. 
In all doubtful cases in which the restlessness of the child interferes 
with a careful examination an anaesthetic should be given. There 
is a characteristic condition which in some cases can be detected by 
examination. As the finger is inserted into the anus the rectum is 
felt to be inflated. This is due to traction on the gut by the in- 
vagination. I have found this inflated state of the rectum in two 
infants suffering from intussusception. 

Spontaneous Cure. — There is little doubt of the possibility of 
spontaneous recovery in invagination ; such cases have been recorded 
by competent observers. Henoch has seen typical intussusception 
retrograde and the patient recover. There is another mode of 
recovery which occurs in cases of irreducible intussusception : the 
intussusceptum sloughs off and is passed per anum. This occurred 
in 43 per cent, of the unrelieved cases (Leichtenstern), but in 40 per 
cent, of these the patient succumbed to general sepsis with or with- 
out peritonitis or to subsequent obstruction of the gut from swell- 
ing after the gangrenous portion was passed. Henoch reported a 
case of this kind. 

Treatment. — The diagnosis of intussusception once made, the 
case is one for surgical interference. The sooner surgical treatment is 
begun, the better the chances of recovery. Injections of air, gas under 
pressure, and enemata of w^ater and oil have been tried, with some 
measure of success. Their use, however, delays the radical treatment, 
and apparent improvement frequently gives way to an exacerbation 
of symptoms. Surgical aid then comes too late. The objections to 
the treatment by injection are as follows : the gut is viable in these 
cases, and is liable to be ruptured by injection of gas or air under 
pressure ; an enema of water under only four feet of pressure has 
been known to produce this result. Snow published a case in which 
an injection of oil was made ; post mortem the oil was found above 
the point of obstruction. The enema may thus pass through the 
lumen of the gut without relieving the intussusception. Enemata 
should be given, if at all, during the first forty-eight hours, and 
should be allowed to flow into the rectum under very low pressure. 
The amount of fluid varies ; certainly not more than a quart should 
be given. The fluid, a saline solution at 100° F. (37.7° C), is 
allowed to remain in the rectum for ten minutes, the patient being 
under an anaesthetic. A Davidson syringe should not be used. The 
ordinary bag irrigator is best for this purpose. If one enema fails 
and the diagnosis is certain, there should be no delay in seeking 
surgical assistance. 



ACUTE APPENDICITIS. 501 

Appendicitis. 

( Perityphlitis; Paratyphlitis. ) 

Anatomical Peculiarities. — Vallee examined the appeodix in 
100 infants and children post mortem. He found that in fully 75 
per cent, the caecum is situated above the anterior superior spine, 
on the right side, a position higher than that occupied in the adult. 
It is above the plane of the anterior superior spine of the ileum, 
is almost 5 centimetres long, and has a general longitudinal ascend- 
ing or descending direction. In one case the appendix was situated 
entirely to the left of the median line, there being no transposition 
of the other viscera. Knowledge of these facts is of importance in 
the examination for the appendix in conditions of disease. I have 
frequently succeeded in palpating the normal appendix at one side 
of the csecum. It is felt as a cylindrical body having the diameter 
of a quill. 

Acute Appendicitis. 

Frequency. — Although the statistics showing the frequency of 
appendicitis in infancy and childhood vary with the number of cases 
collected by each author, the combined statistics of Matterstock, 
Fitz, Sonnenburg, and Nothnagel, show that the disease is not very 
frequent before the tenth year. Only 8 per cent, of the cases occur 
at this age. It may occur in early infancy. Savage records a case 
in an infant two months old ; Demme also records a case in a very 
young infant. 

The literature shows occasional cases at all periods of infancy. 
Among the cases collected and tabulated from the service of my 
colleagues, Gerster and Lillienthal, at the Mount Sinai Hospital, 
there is one of an infant one year of age. Of 50 cases of appendi- 
citis in children taken from the service of these surgeons, 1 occurred 
in an infant one year of age, 17 from the third to the sixth year, 
and 32 from the sixth to the tenth year of life. Thus in a statistical 
collection of cases occurring in children, only one-third occurred 
before the sixth year of life. 

The forms of the disease are the same as in the adult subject. 
The perforative form seems to be the most common among children. 
Thus of 50 cases coming to the hospital for operation, 31 were per- 
forative wdth or without abscess, 9 were of the gangrenous variety, 
and 6 of the catarrhal form. It will thus be seen that in children 
the tendency in this disease as in others, such as pleurisy, is toward 
suppuration and the formation of abscess. 

The symptoms will vary with the variety, whether catarrhal, 
perforative, or gangrenous. 

a. In the catarrhal form the patient is, after some indiscretion 
in diet, seized with colicky abdominal pain, vomiting, and some 



502 DISEASES OF THE DIGESTIVE SYSTEM. 

fever. In other cases the children simply complain of pain which 
is not sufficiently severe to prevent their being up and about. The 
pain is not always located by the patient in the appendix. When 
the patients are in the recumbent posture, the right knee may be 
flexed and the thigh flexed on the abdomen ; when they walk, they 
do so in a bent position, favoring the affected side. Physical ex- 
amination reveals a localized resistance or tenderness in the right 
iliac fossa. In some cases there is distention of the caecum with 
feces, in others I have felt the appendix and the caecum matted 
together in a mass of the size of the index finger. 

The pain is not always referred to the iliac fossa, but may be 
distinctly located around the umbilicus or over the lower part of 
the abdomen. 

It may not always be possible to palpate the appendix, which 
may be behind the caecum. Under such conditions no intumes- 
cence will be found. McBurney's point will be considered in the 
diagnosis. 

The history of many of the catarrhal cases is one of recovery 
under careful treatment. The fever subsides or may never have been 
above 101° F. (38.3° C.) ; the pain also subsides, and in from a 
few days to a week the patient is apparently well. Attacks of this 
kind may recur. 

6. In the perforative or suppurative form the symptoms are more 
violent. In this form also the onset of the disease seems to date from 
some indiscretion in diet. The patient is seized with sudden sharp 
pains in the abdomen, accompanied by vomiting, fever, and rapidity 
of pulse. The pain is located either in the upper or the lower part 
of the abdomen, or in a few cases in the right iliac fossa. After 
one or two attacks of vomiting this symptom may subside and not 
recur until the second or third day, when perforation occurs. Tym- 
panites occurs early and may set in after the second day of the dis- 
ease. The pain and tympanites cause an increase in the respiratory 
movements, which are shallow. The patients lie in the recumbent 
posture. The tympanites, if the perforation is extensive and there 
is general peritonitis, causes, as in all forms of perforation, a disap- 
pearance of the liver dulness. The pulse is at first rapid and thready, 
and quickly mounts above 120 after perforation has occurred. The 
prostration is great, and in some cases of a septic type jaundice is 
present. 

c. In the gangrenous form the symptoms are very similar to 
those of the perforative form, but are very much intensified. It is 
not possible to tell from the symptoms whether the process is gan- 
grenous, simply perforative, or catarrhal followed by abscess. 

Course. — In both the perforative and the gangrenous cases in 
children as in the adult, localized adhesions may form with a small 
or large collection of pus or several foci of pus. In other cases a 



ACUTE APPENDICITIS. 503 

general peritonitis follows the perforation. In children, as in adults, 
the moment of perforation is followed by a temporary fall in the 
temperature and a cessation in the pain and vomiting, the pulse, 
however, continuing rapid. The lull, however, is of short duration, 
and is quickly followed by an increase in the severity of the symp- 
toms. 

Diagnosis. — The above outline gives very little idea of the great 
and sometimes insurmountable difficulties of diagnosis of appendi- 
citis in young children. To guard against error, a very careful 
routine should be followed. The patient is completely undressed 
and lies in the recumbent posture, the shoulders being slightly raised. 
The physician should stand or sit at the patient's right. The contour 
of the abdomen is noted. If it is normal and not distended, there is 
probably no peritonitis. The abdomen is very gently palpated in differ- 
ent places to ascertain if there is distributed or localized tenderness. 

Fig. 99. 




.^r-***f<% 










Method of examination of the region of the appendix vermiformis. 

The left palm is then placed underneath the right loin, and w^ith the 
palmar surface of the fingers of the right hand the region of the 
appendix is gently palpated (Fig. 99). Superficial palpation is 
practised at first. The hand is then depressed deeper into the iliac 
fossa in search of resistance or tumor. The intensity of the pain 
caused by manipulation is carefully gauged by watching the face of 
the patient. The right iliac region having being carefully palpated, 
rectal exploration should be made in all doubtful cases. This is 
necessary in the cases in Avhich a general tympanites or general 
abdominal tenderness makes the diagnosis difficult. With the Avell- 
oiled index finger of the right hand the rectum is explored as high 
up as possible. In young children this can be done Avithout causing 
pain if gentleness and caution are exercised. If children are very 
intractable, this method of examination cannot be carried out. 



504 DISEASES OF THE DIGESTIVE SYSTEM. 

The following points are important in the diagnosis : 

Tympanites. — If the abdomen is distended and there is general 
pain with increase of the number of respirations, there is probably 
peritonitis localized or diffuse. In the latter case there is disappear- 
ance of the liver dulness if the tympanites is extreme. 

Percussion will sometimes, . even in general peritonitis, give a 
localized dulness in the right iliac fossa. Localized pain and in- 
tumescence or a localized mass in the right iliac fossa are of great 
import. 

McBurney's point is of less value in children than in the 
adult. In children, as will be seen from Vallee's work, the appen- 
dix is situated higher than in the adult, and McBurney's point is 
therefore too low for palpation. Some children complain of epi- 
gastric, others of umbilical pain, which is not so distinctly localized 
as in the adult. 

The fever is of little value, there being nothing characteristic in 
the curve. The temperature may be normal or in severely septic 
cases slightly raised. After perforation, the temperature becomes 
subnormal, as it does in the adult. 

Appendicitis in children may simulate tuberculous peritonitis. In 
the latter disease there is sometimes severe pain of the colicky 
variety. Tuberculous peritonitis and appendicitis may be coinci- 
dent. 

Pain in appendicitis resembles very closely that in gastro-enteritis 
and dysentery. Griffith has published 2 cases of appendicitis in 
children who had entero-colitis at the same time. 

I have had one case in which a perinephritic abscess simulated an 
appendicitis. The contrary may also occur. Appendicular abscess 
may simulate a coxalgia with abscess. I have seen a few cases of 
typhoidal affection of the appendix which for a few days simulated 
an appendicitis very closely. Appendicitis with invagination of the 
appendix into the caecum is a rare condition, as is also intussuscep- 
tion with appendicitis. In the typhoidal cases, a Widal reaction 
may be obtained, and will be of assistance in diagnosis. Care 
should be taken that a perforating typhoidal ulcer does not escape 
diagnosis. Intussusception will give the characteristic symptoms 
of that condition. 

I have seen cases of lobar pneumonia of the lower lobe of the 
right lung, in which the pleuritic pain radiated down the right 
side into the iliac fossa. There were also epigastric pain and 
vomiting at the onset of the disease. The excessive rapidity of the 
respirations, the marked dyspnoea, and absence of tympanites and 
pain on deep pressure in the region of the appendix, led me to 
examine the lung. 

Prognosis. — Of the 50 hospital cases which I have tabulated 
above, only 3 recovered without operation ; they were of the 



CHRONIC APPENDICITIS. 506 

catarrhal variety. These figures give no accurate idea of the pro- 
portion of recoveries made under careful and conservative treatment 
in private practice. 

The mortality in the cases operated upon was 35 per cent. The 
rate is not high considering that many cases came under the knife 
later than would have been the case in private practice. On the 
other hand, it should be remembered that the rate of mortality is also 
influenced by the nature of the infection and the power of resistance 
of the patient. Thus cases with a gangrenous appendix died although 
operated upon on the second day ; others of the same kind recovered 
although the disease had lasted from four to seven days before opera- 
tion. Some perforative cases died on the second or third day of the 
disease, while others recovered although operated upon from six to 
twelve days after the onset of symptoms. Gangrenous cases in 
this statistical table in children show a lower rate of mortality than 
those cases in which the appendix perforates, forms an abscess, and 
causes general peritonitis. 

Chronic Appendicitis. 

This form of appendicitis occurs in older children. The cases 
are frequently mistaken for those of dyspepsia, and vice versa. The 
history is much the same as in the adult. A child otherwise in 
good health has attacks during which there is abdominal pain not 
of great severity, but which may last for a few hours and disappear, 
leaving the patient well. The pain is very rarely referred to 
the appendix ; it is abdominal, the umbilical region being gener- 
ally indicated as the seat of discomfort. The temperature may reach 
100° F. (37.7° C.) ; the pulse in a child of eight years was 96 
and regular. There is no vomiting and no prostration. The pain is 
sufficiently severe to make the patient wish to lie down ; it is not 
excessive when the appendix is palpated. The bowels are regular. 
The cases may in the intervals between the attacks show a slight 
intumescence in the region of the appendix, but nothing is felt in 
the rectum. The signs in the interval may be very indefinite or 
quite distinct. The caecum and appendix are felt to be matted to- 
gether. Three cases in which there had been repeated attacks extend- 
ing over a period of from one to two years, were operated upon for 
me by leading surgeons. The patients were girls between the ages 
of six and eight years. In each case there was evidence of a chronic 
catarrhal process. In one case the appendix contained a fecal cal- 
culus, in another there were constricting adhesions. 

The treatment of both acute and chronic appendicitis in in- 
fants and children does not differ from that followed in the adult 
subject. 



506 DISEASES OF THE DIGESTIVE SYSTEM. 



Rectum. 

In infants a large portion of the rectum is situated in the abdominal 
cavity rather than in the pelvis. It has three curves — one lateral 
and two anteroposterior. The gut is nearly straight and occupies 
a more or less vertical position, hence the frequency of prolapse. 
The attachment of the rectum to the surrounding parts is not 
extended as high in children as in adults, hence the rectum is more 
liable to be pushed out. The rectum of the newborn infant may 
be divided into three parts. The first lies in front of the sacrum 
and ends at the lower end of the bone ; the second is short, 
and in this respect differs from the adult gut, being also more 
vertical ; the third portion is long, and extends downward and some- 
what backward. The second portion being short, when the rectum 
is distended, the gut is straightened out and the whole rectum 
extends downward and backward (Symington). All these data are 
of importance in applying methods of therapy (enteroclysis, etc.) to 
this organ. 

Prolapsus Ani. 

Prolapsus ani is a condition frequently met with in infants and 
children. It may amount only to an eversion of the mucous 
membrane. There is in some cases a complete descent of part of 
the rectum, which protrudes from the anus to the length of one or 
two inches. 

The etiology of this condition is obscure. It evidently occurs 
only in cases iu which the pelvic attachments of the lower bowel 
are lax. It is favored by anatomical conditions elsewhere mentioned. 
It is seen in children who are constipated, in those who suffer from 
diarrhoea, and also in those whose movements are not normal. Any 
abnormal condition in the neighboring organs, such as the bladder 
and urethra (stone), may cause excessive straining and consequent 
prolapse of the gut. A rectal polypus may cause prolapse. 

Symptoms. — In some cases the only symptom is the appearance 
of a small quantity of mucus and blood on the diaper with each 
movement ; in these cases the prolapse returns spontaneously. In 
other cases the bowel descends to the extent of one or two inches 
with the movement, and remains prolapsed. If a polypus of the 
lower part of the rectum is the cause of the prolapse, it is seen pro- 
truding from the prolapsed portion. 

Treatment. — The first step is to replace the protruding gut. 
The gut is anointed with olive oil or vaseline and gently replaced 
with a towel. The movements are so regulated by diet and cathar- 
tics that the stools are passed without straining. Three times daily 
a suppository containing grains ij to iij (0.12 to 0.2) of tannic acid 
is placed in the lower bowel. While the movements are being passed 



SPASM OF THE ANUS. 507 

the patient is kept in the recumbent posture on a bedpan. This treat- 
ment is frequently successful. In other cases, the buttocks are drawn 
together by adhesive straps and the child is allowed to pass move- 
ments thus strapped. Cocaine and strychnine are used both in sup- 
positories and hypodermically. The protruding portion is painted 
with cocaine. These measures have their failures and successes. 
The only satisfactory method is that first advised — of a strict diet, 
the recumbent posture at stool, and the astringent suppository. The 
Paquelin cautery is sometimes employed to cauterize the mucous 
membrane. The danger in this method is the substitution of a 
traumatic stricture of the anus for the comparatively harmless pro- 
lapse. Application of the pure stick of silver nitrate to the anus 
twice a week, has given good results. If a polypus of the rectum is 
the cause of the prolapse, the growth should be removed by surgical 
means. 

Fissure of the Anus. 

Fissure of the anus is seen in syphilitic infants, in those suffering 
from marked constipation, and in infants that have eczema of the 
anus. It may be the result of the repeated introduction of the hard 
nozzle of an enema syringe. The fissure may be so slight as to be 
only a line-like tearing of the mucous membrane, or may consist of 
a broad ulcer with a hard granulating base. 

Symptoms. — As a rule, the infants are constipated. When a 
movement is passed, the infant cries and there is great pain. A few 
drops of blood are passed on the diaper. 

Diagnosis. — The presence of a fissure of the anus sometimes 
escapes the notice of the physician. If there is a history of the 
above symptoms, the physician should place the infant on a table, 
grasp the buttocks with the palm of the hands and separate them 
forcibly with the thumb. The anus is thus everted, and if a fissure 
is present it will at once become apparent. 

Treatment. — A small fissure is sometimes very successfully 
treated by regulating the bowels. It is touched with a 10 per 
cent, solution of silver nitrate once a day. In the severe cases 
silver applications will not avail ; forcible dilatation of the rectum 
by means of the thumbs must be resorted to. This procedure not 
only cures the fissure, but is also an effectual remedy for the accom- 
panying constipation. 

Spasm of the Anus. 

Cases of nervous spasm of the sphincter ani occur in infants. 
The infant is constipated and cries at each movement. There is no 
bleeding, nor does examination reveal any fissure, but only marked 
contracture of the anal opening. In these cases it is almost impos- 
sible in an examination to bring down the upper part of the anal gut. 



508 DISEASES OF THE DIGESTIVE SYSTEM. 

The remedy is to regulate the bowels. If by this means success 
in overcoming the spasm is not attained, forcible dilatation is the 
only resource. 

Proctitis. 

Apart from the membranous and catarrhal forms of proctitis, 
which occur with similar conditions of the intestine, the only form 
which is of interest is the gonorrhoeal. This occurs as a complication 
of vulvovaginal gonorrhoeal inflammation. In these cases the in- 
troduction of the gonococcus from the vagina into the gut has 
occurred through careless thermometry or the giving of enemata 
without previous cleansing of the parts. The disease is very pain- 
ful and at the same time trying to the infant or child. With the 
discharge of pus from the anus there are tenesmus and a bloody 
discharge with the movements. The purulent discharge shows 
gonococci. 

The treatment consists in the injection of protargol solutions, 
2 per cent., at a temperature of 105° to 108° F. (40.5° to 42.5° C), 
into the rectum twice daily. The bowels are regulated. Supposi- 
tories of tannin or tannigen are also of value and give great relief; 
one containing grains iij (0.18) is given per rectum twice daily. 
In the later stages it may be necessary to paint the lower bowel 
with a very weak solution (0.5 per cent.) of silver nitrate. 

Polypus of the Rectum. 

Polypus of the rectum is not rare in childhood, but is not often 
seen in infancy. It occurs most frequently from the third to the 
seventh year of life. The polypi are adenomata. I have examined 
several, and have found them to have the structure described by 
Baginsky. They may be single or multiple, usually have a pedicle, 
but may be attached to the wall of the gut by a broad base. As a 
rule they are situated on the posterior wall of the rectum seven or 
eight centimetres above the anal ring, but may be on the anterior 
wall. In most cases the polypi exist here only, but I have seen 
them higher up in the gut, and in one case in a child of five years 
from whom several rectal polypi had previously been removed, I 
diagnosed a number in the descending colon. In this case lapa- 
rotomy and incision of the gut proved the diagnosis to have been 
correct. The polypi may, if they become numerous, assume a 
malignant character ; this is especially true of the growths with a 
large, broad intestinal base. 

Symptoms. — The characteristic symptom is intermittent hemor- 
rhages from the gut, which may be profuse. At times the outer 
surface of the movements is streaked Avith blood, the bowels being 
constipated or normal, with an occasional mucous diarrhoea. If the 



INTESTINAL PARASITES. 509 

polypus is low down, there is straining at stool with prolapsus of 
the gut. Many of the children thus aifected are pale, have a pasty 
hue of the skin, and show evidences of lymphatism. 

Diagnosis. — Bleeding from the bowel, in the absence of other 
symptoms, should at once suggest the necessity of digital explora- 
tion of the lower bowel. If a polypus is not found, a careful pal- 
pation of the abdomen made when the patient is fasting should be 
the next procedure. If the child is tractable and the abdomen soft, 
it may be possible to feel a tumor of the size of a hazelnut at one 
side of the umbilicus. 

The prognosis is good ; removal of the polypi is rarely followed 
by recurrence of symptoms, even in cases in which they are situated 
in the descending colon. If they are removable and not very 
numerous, the patient recovers. 

Treatment. — If the polypus is low down and pedunculated, it 
may easily be snared with or without the aid of a rectal speculum, 
and crushed or ligated off. If it is high in the sigmoid flexure, the 
anus should be dilated and the growth reached by means of a specu- 
lum. In cases in which the growth is in the colon, laparotomy, 
enterotomy, and ligation are indicated. 



INTESTINAL PARASITES. 

The most common parasites found in infants and children are 
the Nematoda, or round worms, and the Cestoda, or tapeworms. 
The round worm is smooth and light brown or reddish in color, 
the female being larger than the male. The eggs are found in the 
stools ; they are from 0.05 to 0.06 mm. in diameter and are sur- 
rounded by an albuminous envelope. The worm is several inches 
long. Oxyuris vermicularis is about 1 cm. long, the male having 
a length of 4 mm. The eggs measure 0.05 mm. in their long 
diameter. 

The tapeworms in mature state consist of rectangular segments. 
The head and neck are called the scolex ; the segments, proglottides. 
The worms are hermaphrodites. The solium is sometimes several 
metres long. The head is of the size of a pin's head, with a pro- 
jecting proboscis armed with booklets. The eggs of the solium are 
ovoidal, 0.3 mm. in diameter. The Taenia mediocanellata has a 
more cuboidal head without booklets (Fig. 100). 

Diagnosis. — There are no symptoms which can be traced to the 
presence of these worms in the gut. If they increase in enormous 
numbers, they may cause symptoms of mechanical obstruction. 
Without the presence of the eggs or links of the worm, a diagnosis 
is not possible. Their presence is made known by the passage per 
anus of the links of such worms as the tapeworm. Round worms 



510 



DISEASES OF THE DIGESTIVE SYSTEM. 



may also pass out of the anus, or may be vomited if they gain 
access to the stomach. Thread worms may cause excessive pruritus, 
and may not be discovered external to the anus. In that case the 
feces should be carefully examined for the eggs of the worms. 



Fig. 100. 









1. Oxyuris vermicularis, pin worm, natural size. 

2. Egg of Ascaris lumbricoides. 

3. Egg of Oxyuris vermicularis, pin worm. 

4. Egg of Tsenia solium. 

5. Proglottides or links of Tsenia solium. 

6. Proglottides of Bothriocephalus latus. 

Round Worms. 

( A scar ides Lumbricoides. ) 

This parasite is found in the small gut ; it may invade the stomach 
or may pass downward into the rectum. Cases are recorded (Borger) 
in which it has passed into the bile-duct and caused abscess of the 
liver. There may be only one or many of these worms in the 
gut. Leuckart states that they may form large masses in the gut, 
and thus cause intestinal obstruction. They have been known to 
perforate the gut and cause peritonitis. The eggs are introduced 
into the gut through the medium of drinking-water, fruit, and vege- 
tables. Epstein cultivated the eggs outside of the body and then 
introduced them into the gut, where they developed. The male 
worm is 250 mm. long, the female being longer. 

The symptoms caused when these parasites have once gained 
access to the body are not characteristic. I have seen the worms 
passed or vomited by children apparently in normal condition. 

The treatment consists in placing the patient on a milk diet. 
After a few days the following powder is administered two or three 
times daily : 

Calomel, 

Santonin aa gr, J (0.016). 

Santonin is sometimes administered in the form of pastiles, but is 
not niore satisfactory than the ^bove preparation. 



TAPEWORM. 511 

Oxynris Vermicularis. 

(Pin Worm; Thread Worm.) 

Brass showed that the habitat of these worms is the small intes- 
tine, whence they pass into the csecum. The female worm lays its 
ova in the folds of the gut. They may pass into the stomach and 
thence into the mouth, but more frequently pass out of the anus 
into the vagina or into the prepuce and urethra. They exist in 
enormous numbers in the gut, are exceedingly small, and have 
the appearance of fibres of cotton fabric. They can be seen by 
spreading the nates apart. They are then found in the anus, or in 
female children in the fourchette. The principal symptom is intol- 
erable pruritus, so intense as to deprive the children of sleep. This 
worm is found only in the human subject. It is conveyed from 
person to person through uncleanliness. The larvae adhere to the 
fingers, and thence are introduced into food-stufFs. 

Treatment. — It is a very difficult task to dislodge these worms ; 
injections by the rectum cannot reach those higher in the intestine. 
The plan which I have followed, and which gives relief, is to give 
daily enemata of quassia wood before bedtime : 

Quassia wood (ground) . . , ,^ j (31.0). 

Aquffi dest Oj (500.0). 

Make an infusion and strain. 

I have in addition utilized the prescription of santonin and calomel 
given above for the round worms. 

Schmitz recommends the administration of naphthalin, grains 
j to iij (0.06 to 0.18), t. i. d., for a week, after which it is discon- 
tinued for a few days, and then given again. 

Tapeworm. 

{Toenia.) 

Tsenia are quite common in children, and have been found in the 
newborn infant (Miiller and Armor). Numerous cases have been 
recorded of the presence of these worms in infants from the third to 
the twelftii month. They are most frequently found between the 
first and the third year. The varieties most commonly found in 
children are : Taenia solium. Taenia mediocanellata, Taenia elliptica, 
Bothriocephalus latus. 

Sources of Origin. — Taenia Elliptica. — The lice of the house-dog 
and cat are introduced by the fingers of the children into their 
mouths, and thus gain access to the gut. There the larvae of the 
tapeworm which they contain develop. 

Taenia Solium. — The larvae of this worm are found in badly 
cooked pork or beef. 



512 DISEASES OF THE DIGESTIVE SYSTEM 

Taenia Mediocanellata. — The larvae of this worm are found in 
beef. Bothriocephalus latus is introduced by the ingestion of in- 
fected fish-food. 

The larvae of tapeworm may exist in the flesh of the hare, pigeon, 
pheasant, chicken, goose, or duck. Ice if made from infected 
water may be a means of introducing the larvae in the body. It is 
thus not necessarily the meat-eating children who run the danger of 
swallowing the larvae of tapeworm ; milk if diluted with infected 
water may contain them. 

Symptoms. — Tapeworms may exist for months or years in the 
body of a child without causing untoward symptoms. As many as 
three varieties of the worm have been found in the same child. 
The symptoms are not characteristic. The passage in the move- 
ments of the links of the taenia is the only positive evidence of 
their presence. 

Treatment. — The only successful treatment for the expulsion of 
the tapeworm is that which consists in the administration of filix 
mas in some form. It should be freshly prepared and given in 
liberal doses : Ext. aeth. filix mas, Tl^xxx (2.0) to 3j or ^ij (4.0 
or 8.0), is made into an emulsion with gum tragacanth, and mixed 
with equal parts of castor oil. The administration of this mixture 
is preceded by a day or more of milk diet. The child is then given 
from half a drachm to a drachm (2.0 to 4.0) of the filix mas with 
castor oil in divided doses. The recumbent posture is maintained 
in case nausea should be experienced. The movements containing 
the worm are carefully washed through a sieve, and the smallest part 
of the worm sought for in order to see if the head has come away. 

The patient should be given a drawing of the comparative size 
of the head and links of the worm, in order that the head may not 
be lost, or the physician may seek it himself. 

References of Authorities for Collateral Heading. 

Amberg, S. : "A Contribution to Amoebic Dysentery," etc, Johns Hopkins Bull., 
December, 1901. 

Borger, G. : " Ascaris Lumbricoides," etc., Arbeit, aus der k univ. Kinderlinik, 
Munich, 1891. 

Biedert, P. : Diiitetische Behandlung der Yerdauungs storungen, Stuttgart, 1901. 

Booker, Wm. : "A Bacteriological and Anatomical Study of the Summer Diar- 
rhoeas," etc., Johns Hopkins Hospital Rep., vol. v. 

Beck, Carl: ''Appendicitis," Volkmann's Vortrage, No. 221. 

Czerny and Keller : Ernahrungstorungen, 1901. 

Epstein, A. : " Beobachtungen iiber Monocercomonas," etc., Prager med. 
Wochen., 1893. 

Escherich, T. : Streptokokken Enteritis, Jahrbuch. f. Kinderheilk., Bd. XLIX. 

"Dysenteric," Central bl. f. Bakt., 1899. 

"^tiol. der Primaren ac. Magen Darm Krankheit," Wien. med. Wochen., 

1900. 

Filatow, N. : Darmkatarrh der Kinder, Vienna, 1893. 

Gibson, C. L. : " One Thousand Operations for Acute Intestinal Obstruction," 
Annals of Surgery, 1900. 



DISEASES OF THE LIVER 513 

Gregor : Fettgehalt der Frauenmilch, etc., Volkmann, 1901. 

Heubner, 0. : "Atrophie," Jahrbuch. f. Kinderheilk., N. F. liii. 

Gedeihen u. Schwinden, Berlin, 1898. 

llloway : " Constipation in Adults and Children." 

Leuckart, R. : Die Parasiten des Menschen, Leipzig, 1894. 

Marfan, A. B. : Gastro-enterites des Nourissons, Paris, 1900. 

Traite de 1' Allaitement, Paris, 1899. 

Morse, J. L. : " Renal Complications of Acute Enteric Diseases," Trans. Amer. 
Ped. Soc, 1899. 

Nicoll, I. H. : "Congenital Stenosis of the Pylorus," Pediatrics, 1901. 

Pfaundler, M. : Ueber Stoffwechsel Storungen, Berlin, 1901. 

Magen Capacitat, etc., Bibliotheca Medica, Stuttgart, 1898. 

Pritchard, E. : " Congential Pyloric Stenosis," Arch, of Ped., 1900. 

Spiegelberg, I. H. : Arch. f. Kinderheilk., Bd. xxvii. 

Thomson, John : "Congenital Hvper. of the Pylorus," Edinburgh Hospital Eep., 
1896— Scott. Med. and Surg. Jour., 1897. 

Treves, F. : Intestinal Obstruction, New York, 1900. 

Vallee, P. H. : Situation du Ccecum, These, 1900. 

VI. DISEASES OF THE LIVER. 

Anatomical. — The weight of the liver in infants and children 
is from one-twentieth to one-thirtieth of the body weight ; in the 
adult it is one-fortieth. 

Examination. — The liver is examined with the patient in the 
recumbent or semirecumbent posture. The physician may palpate 
for the liver or mark out the organ more accurately by percussion. 
In marking out the organ, the upper limit, the lower edge, and the 
area of superficial dulness are determined. Perfect accuracy by 
deep percussion is not feasible, because in order to obtain absolute 
dulness some force must be used, and vibratory echoes of other 
neighboring organs — the lungs and intestines — are thus caused. In 
all cases it is well to determine the upper limit of dulness at a 
point where the liver comes in contact with the chest-wall. 

The lower border of the liver is determined by palpation and 
percussion. The lower border projects normally in infants and 
children below the border of the ribs. In the right mammillary 
line this projection may vary from 1 to 2.5 cm. At the xiphoid 
appendix the liver may project to the extent of 2 to 6 cm. and still 
be within the normal limits. These conditions may exist up to the 
tenth year. The exact age at which the liver assumes the adult 
dimensions has not been determined. In some adults, however, 
the projection below the border of the ribs is the same as in chil- 
dren. Since the size of the liver varies, caution should be exercised 
in pronouncing the organ enlarged. The gut, ascites, and tympan- 
itic distention may obscure the lower limit of the liver both to pal- 
pation and percussion. 

Palpation. — By palpation, the location of the lower border of the 
liver may be determined, and whether it is rounded or sharp, also, 
if the liver be enlarged, the character of the projecting portion, 
whether smooth or uneven. In infants and children the region of 



514 



DISEASES OF THE DIGESTIVE SYSTEM. 



the gall-bladder is palpated, but it is difficult to determine in these 
subjects whether this organ is enlarged or absent. Henoch and 
Murchison have recorded fatal cases of increasing and persistent 
icterus in which there was congenital absence of the gall-bladder. 

Percussion. — Percussion should be performed in the mid-line 
from the base of the xiphoid cartilage downward, in the right 
mammillary line from above downward, and sometimes in the mid- 
axillary line. In order to determine accurately the superficial dul- 
ness, the whole extent of the duluess should be measured. This is 
rarely necessary except in investigations for scientific purposes. In 
cases of effusion into the pleural cavity, the upper limit of dulness 
is continuous with the dulness or flatness of the fluid. The displace- 
ment below the border of the ribs only can then be determined. 
In rare cases of subphrenic abscess there is an extension of the 
upper limit of dulness into the limits of the chest cavity, and 

Fig. 101. 




Method of palpating the projection of the liver below the ribs. 

displacement of the lower border of the liver downward. Steffen 
gives the following measurements of the superficial liver dulness in 
the median and mammillary lines : 

Midline. Mammillary line. 

At birth 3.5 cm. 2 cm. 

At one month 5 *' 5 " 

At six months 4,5 " 4.5 " 

At one year 4.5 '' 4 '' 

At two years 5.2 *' 5 "■ 

At five years . . 5 " 6.5 '* 

At ten years 5 "' 6 " 

These measurements also vary greatly, especially in infants under 
one year of age. 

The following tumors and conditions simulate enlargement or 
disease of the liver : phantom tumor ; circumscribed empyema, or 
pleuritic effusion ; subphrenic abscess ; circumscribed peritoneal 



DISEASES OF THE LIVER. 515 

eifusion between the liver and diaphragm ; tumors or cysts of the 
right kidney. 

Phantom tumor is described by Murchison. It is a soft or 
hard epigastric tumor, which may project downward as far as the 
mnbilicus. Whether it is dull with a tympanitic note, or tympanitic, 
depends on the amount of muscular contraction. There is no fluc- 
tuation or flatness. The tumor is present when the patient is stand- 
ing or in the recumbent position. It disappears under anaesthesia. 
A tumor of this kind should not be punctured until it has been 
observed under ansesthesia, since there is danger of puncturing the 
intestine and causing peritonitis. ^ 

Empyema. — In simple or encapsulated empyema on the right 
side, the liver is displaced downward. The upper dulness extends 
into the pleural cavity ; the lower part of the thorax may enlarge 
to such an extent as to press the ribs apart and cause fluctuation 
between them. There will be dulness or flatness in front or behind 
over the lower part of the pleural space, and perhaps disappearance 
of the respiratory murmur. It should not be forgotten that there is 
always a possibility of the presence of subphrenic abscess, or of 
abscess in the upper part or on the surface of the liver, bulging into 
the pleural cavity. In that case there will not only be bulging of the 
lower ribs, but also a continuation of dulness for a variable distance 
upward. The liver may be enlarged downward or not at all. If 
the tumor is beneath the diaphragm and displaces the liver down- 
ward, the respiratory murmur may be heard to the normal, or almost 
normal, limit, and yet dulness due to the upward projection of the 
tumor may be present. 

Kidney tumor may extend from behind, beneath the liver, and 
simulate liver tumor. In such cases, the lumbar flatness extending 
below the border of the ribs will be a guide. 

Enlargements of the Liver. — Enlargements of the liver 
in infancy and childhood present much the same physical signs as in 
the adult, but there are some states which are peculiar to early life. 

Anaemia infantum pseudoleuk.emica of von Jaksch 
causes great enlargement of the liver and spleen. The lower edge 
of the liver is rounded ; the lymph-nodes are enlarged, and the 
blood presents certain features characteristic of this anaemia. 

Simple rachitis causes slight or marked enlargement of the 
liver, as well as real enlargement of the spleen. In some cases, the 
liver is not really enlarged, but may be displaced downward by the 
deformity of the thorax. Simple icterus usually causes enlargement 
of the liver, which retrogrades after a few weeks. 

Congenital syphilis may cause slight enlargement of the 
liver which, up to the end of the second year, is present without 
icterus. The liver is enlarged in cirrhosis, abscess, and fatty degen- 
eration of the organ. It is greatly enlarged in acute and chronic 
leukaemia. 



516 DISEASES OF THE DIGESTIVE SYSTEM. 

Jaundice. 

{Catarrhal Icterus; Catarrhal Jaundice; Infectious Icterus.^ 

Simple jaundice is a common disease of infancy and childhood. 
In its simplest form, it was formerly believed to be due to an 
obstruction of the common bile-duct with mucus. In recent years, 
the French clinicians have described a form of jaundice which they 
regarded as infectious. The first cases of the kind were published 
in 1881 by Weiss, Chauffard, and Landouzy, in France, and by 
Weil, in Germany. There is at present a tendency to regard all 
cases of jaundice in infants and children, not due to mechanical 
obstruction of the duct or disease of the liver, as infectious (Botkin, 
Hennig, Barthez, Henoch, and others). Thus simple icterus would 
be regarded as a mild form of infectious icterus. This view has 
recently been elaborated by Kissel. The theory, that errors of diet 
cause a catarrh of the gut, extending into the duct and thus 
obstructing it, finds little support. On the other hand, the theory 
of the infectious nature of even the mildest cases of jaundice is sup- 
ported by the fact that these cases occur in groups and epidemics. 

Morbid Anatomy. — In cases of fatal icterus, there are found 
atrophy and fatty degeneration of the liver cells. The interstitial 
tissue around the portal vein is infiltrated with small round cells. 
There is parenchymatous degeneration of the kidney. The whole 
picture resembles that of acute yellow atrophy. The mild cases of 
icterus have not yet been studied. 

Bacteriology. — The bacteriology of the severer form remains to 
be studied. In one case Jager found a bacillus of the proteus 
group in the urine. 

Occurrence. — The disease may appear at any period of infancy 
and childhood. It is most common between the second and fifth 
years. 

At present, all primary forms of jaundice may be clinically clas- 
sified as follows : The very mild forms (catarrhal icterus); the severer 
forms ; the fatal forms. It is highly probable that all are infectious 
in origin. The secondary forms of jaundice are not considered in this 
section. 

Symptoms. — In the mildest forms there are no symptoms at the 
onset. In some mild cases there are vomiting and fetor of the breath, 
and the tongue is coated. The skin assumes a saffron hue and the 
conjunctivae are distinctly yellow. The appetite is capricious ; the 
urine is brownish and contains bile-pigment. The movements are 
like clay, and may have a bad odor. There is pruritus of the sur- 
face. The child may be somewhat depressed. In the very mild 
forms there is no febrile movement. In the majority of cases, there 
is rapidity of pulse and, in some cases, irregularity. In the severer 
forms the symptoms are more marked. The vomiting recurs at 



CONGENITAL OBSTRUCTION OF THE BILE-DUCTS. 517 

intervals, the intensity of the jaundice is much the same as in the 
mild forms, and the temperature may in the course of the disease be 
raised a degree or more. The attack may be ushered in by a chill. 
There is some prostration and, in a few cases, diarrhoea. The fatal 
cases, which were first described by Weiss and the French school, 
are severer forms of infection. The symptoms of cholsemia are 
much more marked. There are delirium, unconsciousness, and 
cerebral symptoms. The pulse is greatly increased and the respira- 
tions are irregular. The patients die in an asthenic state. 

The liver is enlarged in even the mildest forms. In a recent 
series of 20 cases of mild icterus, I found the liver enlarged from 
four to seven centimetres below the border of the ribs, in the mam- 
millary line. The spleen was enlarged in most cases. The fact that 
in the mildest forms there is enlargement of the spleen lends support 
to the infectious theory of the disease. In the majority of my cases, 
the liver remained enlarged long after the icterus had disappeared. 
Kissel also found this to be the case. In some cases, three months 
elapsed before the liver returned to the normal limits. 

Duration. — The disease, even in the mild form, lasts from two to 
three weeks. The fatal forms may run their course much more rapidly. 

The treatment of icterus is very simple. An initial dose of 
calomel is given and the bowels are well evacuated. The patient is 
put on a milk diet, and is given, a daily enema of water at a tem- 
perature of 85° F. (29.4° C). On every second day a small dose of 
calomel, grain J (0.03), is given to aid the enemata. Fresh air and 
daily alkaline baths are beneficial. Alkaline baths are made by 
adding a few tablespoonfuls of sodium carbonate and an equal quantity 
of salt to the water. 



Congenital Obstruction of the Bile-ducts. 

The etiology of this affection is obscure. Some 70 cases of this 
condition were recently collected by Morse from the literature. The 
infants may be apparently normal at birth. Intense jaundice is the 
first symptom noticed at birth, or on the second to the fourth day 
after birth. Meconium is first passed by the infant, and then the 
stools are clay colored. The urine contains biliary coloring-matter. 
The liver is enlarged, as is also the spleen. Hemorrhages from the 
stomach and intestine and into the skin occur in time. Death occurs 
early, or in from three to eight months. 

Morbid Anatomy. — Some portion of the bile-ducts may be 
obliterated and replaced by connective tissue. In other cases the 
walls of the ducts are simply swollen. The liver is enlarged and 
the seat of cirrhotic changes. 



518 DISEASES OF THE DIGESTIVE SYSTEM. 



Cirrhosis of the Liver. 

This disease is rare in infancy and childhood. Of 62 cases col- 
lected from the literature by v. Kahlden, 5 occurred in the newborn, 
12 in the first two years of life, and 28 from the ninth to the thir- 
teenth year. It is more prevalent in the male sex. Of those cases 
in which the size of the liver was recorded 19 were atrophic, 15 
hypertrophic, and 6 normal in size. 

Etiology. — Demme has published 2 cases in children addicted 
to the use of alcohol. The influence of heart disease and the infec- 
tious diseases, such as scarlet fever and measles, in causing cirrhosis 
of the liver is not as yet understood. Cirrhosis of the liver occurs 
in forms of peritoneal tuberculosis and in syphilis. 

The morbid anatomy of the affection is the same as in the adult. 

The symptoms, which are the same as in the adult, include en- 
largement of the liver and spleen, icterus, and ascites. The icterus 
is, as in the adult, constant. 

The liver is not always enlarged, and in the cases in which it is 
of normal size the difficulties of diagnosis are increased. The spleen 
is most constantly enlarged. 

The recorded cases of cirrhosis following or complicating the 
exanthemata and diphtheria gave no previous symptoms. ' 

Fatty Degeneration of the Liver. 

Fatty degeneration of the liver, with or without enlargement of 
the organ, occurs in forms of subacute and chronic constitutional 
dyscrasia. I have seen this disease in infants who died with tuber- 
culosis, chronic or subacute intestinal diarrhoea, rachitis, Henoch's 
purpura, or acute leukaemia. I have also seen it in cases of phos- 
phorus-poisoning. The symptoms and signs do not differ from 
those seen in the adult. The diagnosis can hardly be made during 
life. 

Syphilis of the Liver. 

Enlargement of the liver is common in syphilis of infants and 
children. The spleen may also be enlarged. There may be icterus. 
There may be other symptoms of syphilis, but none which can be 
traced to enlargement of the liver. 

There are four histological forms of this variety of hepatic en- 
largement : 

a. The form in which gummata are found in the liver. This is 
rare. I saw a case in an infant sixteen months of age in which 
there were also gummata of the cranial and the long bones. 

b. The diffusely cirrhotic liver. In this form the connective 
tissue is quite evenly distributed throughout the liver. 



ACUTE YELLOW ATROPHY OF THE LIVER. 519 

c. The lobulated liver, in which the connective tissue divides the 
organ into sections. I have seen a case in a girl eight years of age. 

d. The so-called miliary syphilis of the liver, in which the organ 
is strewn with miliary collections of round cells closely resembling 
miliary tubercle. The nodules are situated in the interstitial con- 
nective tissue. They rapidly undergo fatty degeneration. 

Clinically the cases which I have met were mostly those in which 
the liver, hard and nodular, could be felt below the border of the 
ribs. In one case there was a history of syphilitic accidents, in 
another old cicatrices existed on the lips and face. In a third case 
the patieut had Hutchinson teeth ; the liver and spleen were both 
enlarged and nodular. 

Abscess of the Liver. 

{Suppurative Hepatitis.) 

This disease occurs in the newborn as a form of sepsis. Other- 
wise its etiology in infancy and childhood is identical with that in 
the adult. It may follow a traumatism or complicate appendicitis 
(septic), it may occur in peritonitis with pyelophlebitis, or it may 
follow the infectious diseases. In the literature rare cases are de- 
scribed, in which Ascarides lumbricoides have caused abscess of the 
liver in children, by migrating into the gall-bladder through the 
common duct. 

The occurrence of this disease, though not rare in tropical coun- 
tries, is less frequent in districts in which dysentery is not endemic. 
It may occur as early as the fifth month of infancy (Oliveira). The 
left lobe of the liver is most frequently involved. The Amoeba coli 
is not always the cause, being an etiological factor in 20 per cent, of 
the cases. The symptoms in these cases are first those of dysentery ; 
then, after improvement sets in, the symptoms of abscess, with fever, 
swelling of the abdomen, and enlargement of the liver upon palpa- 
tion appear. The liver may enlarge as much as 10 cm. below the 
tip of the ensiform cartilage. 

Course. — The abscess may perforate into the gut, pleura, or 
peritoneum. If it perforate into the gut recovery results. Any 
other termination is disastrous. 

The treatment of abscess of the liver in children is much the 
same as in the adult. If operated early the prognosis is good. 

Acute Yellow Atrophy of the Liver. 

The disease is extremely rare in infancy and childhood. Lanz 
published a case in a boy four years of age. In that there was no 
splenic tumor or hemorrhages, it differed from the picture in adult 
cases. The cases in the literature are as follows : Pollitzer, infant. 



520 DISEASES OF THE DIGESTIVE SYSTEM. 

one month of age ; Senator, infant, eight months ; Mann, infant, 
ten months ; Greves, infant, twenty months ; Widerhofer, child, one 
and three-fourths years ; Rehn, child, two and one-half years ; 
Loschner, child, three and one-half years ; Mettenhemier, child, four 
years ; West, child, six years ; Merkel, child, six and one-half years ; 
Rosenheim, child, ten years ; Steiner, child, ten years ; Folwarczny, 
child, fourteen years. 

I have seen only one case of atrophic liver. The patient, a boy 
of eleven years of age, with very small kidneys, had nephritis which 
had appeared six years after an attack of scarlet fever. The liver 
dulness became gradually smaller from the time of admission to the 
hospital until death. At autopsy, the liver was found to have one- 
half the normal weight and to be the seat of marked parenchymatous 
degeneration. 

References of Authorities for Collateral Reading. 

Demme: Einfluss des Alcohols, etc., Stuttgart. 1891 

Epstein, A. : '^Gelbsucht bei neugeborenen Kindern," Volkmann's Vortr., 180. 
Edwards, W. A.: "Cirrhosis of the Liver," Archives of Pediatrics, 1890. 
Folger, C. : " Hvpertrophische Leber Cirrhose," etc., Jahrb. f. Kinder., October, 
1900. 

Jaeger : "Weil's Disease," Zeitschr. f. Hygiene, 1892. 

Lanz: "Ac. gelber Leberatrophie," Wien. klin. Wochen., 1896. 

Neumann, H. : " Gewohnliche Gelbsucht," Deutsche med. Wochen., 1899. 

Schlessinger, E. : "Leber Carcinom," Jahrb. f. Kinderheilk., March, 1902. 

Todten, H. : Leber Cirrhose im Kindesalter, Miinchen, 1892. 

Weil: Deutsches Arch. f. klin. Med., Bd. xxxix. 



VII. DISEASES OF THE PERITONEUM. 

Ascites. 

Ascites is a serous effusion into the peritoneal sac, and, as in the 
adult subject, it is generally secondary either to some disease of the 
peritoneum, such as tuberculosis, or chronic disease of the heart, 
liver, or kidneys. It may also be due to some obstruction of the 
portal circulation, caused by enlarged glands or tumors of the peri- 
toneum. Ordinary ascites has the same characteristics in the infant 
and child as in the adult, and is recognized by the same physical 
signs. It is therefore superfluous to go into details in this place as 
to the physical characteristics of the fluid accumulation in the peri- 
toneal cavity of infants or children. 

Some rare forms of ascites may be congenital. In diagnos- 
ing ascites in infants and children, we must be careful not to con- 
found it with local accumulations of fluid due to cysts or tumors 
in the peritoneal cavity. Cysts, or cystic tumors, have local cir- 
cumscribed physical characteristics, and with care they cannot be 



ACUTE PERITONITIS. 521 

mistaken for ascites. There is a form of ascites which occurs rarely 
in children, and of which I have seen one example in a boy six 
years of age. It is called chylous ascites, and is marked by its 
chronicity and the milky or fatty nature of the exudate. It is more 
frequent in adults ; but when present in infants or children, it is 
found between the ages of seven and ten years. In one case re- 
corded by Wicklen, the accumulation followed an attack of pertussis 
in an infant six months of age. 

The etiology of chylous ascites is obscure, although in some cases 
tuberculosis of the peritoneum has been found post mortem. It has fol- 
lowed traumatism, eruptive fevers, or an infection with filaria. The 
symptoms are those of ascites, and it is not until the withdrawal of the 
fluid that the true nature of the affection is discovered. The fluid 
withdrawn has a milky, opalescent appearance, and is of two forms, 
in one of which there is a fine emulsion of fat-globules with red and 
white blood-cells ; the other form contains no such element, but is 
chylous in color. At autopsy various lesions have been found, as 
stated, including tuberculosis, syphilis of the liver, cirrhosis of the 
liver, an enlarged spleen, with lesions of the thoracic duct. In some 
cases there has been tuberculosis of the thoracic duct, or this combined 
with tuberculous disease of the lymph-nodes, with apparent obstruc- 
tion of the lymph-vessels. 

The treatment of ascites in children is carried out along the 
same lines as in the adult patient. 

Acute Peritonitis. 

Acute peritonitis may be general or local, and is due to an infec- 
tion of the peritoneum. 

Etiology. — According to Tavel, Lanz, and Treves, the disease 
is caused by various bacteria, such as streptococci, staphylococci, 
pneumococci, or coli bacteria, but the most active role, even in the 
traumatic and perforative forms, is played by the Bacterium coli 
communis. Krogius examined 40 cases of perforative peritonitis 
following appendicitis, in 20 of which he found two or three species 
of bacteria ; in only 7 cases did he find Bacterium coli alone. The 
species found were generally coli bacteria in combination with 
diplococci, pneumococci, Diplococcus intestinalis, streptococci, coli 
gracilis. The remaining cases contained the Streptococcus pyogenes, 
pyocyaneus, and Proteus vulgaris. The coli, however, was the most 
frequent microorganism found. It is to be remarked that in 21 
cases the Diplococcus pneumoniae was found combined with the 
Bacterium coli. This form must not be confounded with the cases 
in which the pneumococcus is found as the causative agent of peri- 
tonitis, especially in children (l^etter, Sevestre, and others). 

We may have : (1) Acute tuberculous peritonitis. (2) Perfora- 



522 DISEASES OF THE DIGESTIVE SYSTEM. 

tive peritonitis, due to traumatism or some pathological perforation 
of the viscera or the serous coat of the intestine as a result of tuber- 
culosis, typhoid fever, dysentery, perforating ulcer of the stomach or 
duodenum, abscess of the liver, cyst of the liver, kidney, or spleen, 
rupture of the gall-bladder, strangulated hernia, intestinal intussuscep- 
tion, appendicitis, perforating lumbricoides — all these can be accom- 
panied by the escape of gas, faecal matter, bile, or blood into the peri- 
toneal cavity. (3) Peritonitis may take place by extension, as is 
observed in cases where inflammation extends from a viscus without 
perforations. (4) Peritonitis may occur as the result of traumatism, 
as a blow or fall or an operation. (5) Pneumococci may cause an 
acute primary peritonitis, or may give rise to the affection by ex- 
tension from the pleura or lung. (6) There is a gonorrhoeal form of 
peritonitis. (7) Peritonitis may occur in the foetus or in the new- 
born. The latter has been described by Billard as following intra- 
uterine infection, as a result of maternal disease ; or in the newborn 
peritonitis may be caused by streptococcal infection of the umbili- 
cus, and extension from this point to the peritoneum. 

The symptoms of acute peritonitis at the onset may be insidious. 
Such forms occur in cachectic, marantic infants, or children ; or the 
onset may be acute and sudden, as in the primary form. 

Pain may be localized either in the iliac fossa or around the 
umbilicus, spreading thence over the whole abdomen. The child 
lies quietly on the back, with superficial respiratory movement. 
There is, as in the adult subject, meteorism or tympanites. There 
is vomiting, first of tlie contents of the stomach, then the vomitus 
becomes green or biliary. It may subside after two or three days. 
There may be a diarrhoea, but in most cases there is constipation as 
obstinate as in intestinal obstruction. The tongue is moist, then 
dry ; the buccal mucous membrane may be covered with sprue ; the 
urine may be suppressed, and, as in the adult, there may be facies. 
The pulse ranges from 120 to 150, small and thready. The fever 
varies in extent, depending very much on the acuity of the infec- 
tion. In perforative peritonitis there Avill be a sharp rise of tem- 
perature. 

The physical signs are much the same as are found in the adult. 
There is tympanites, the abdomen is distended, there is a disappear- 
ance of the liver dulness. In localized peritonitis there is local 
pain ; in general peritonitis the pain is general. If the peritonitis 
becomes general, there is, as a rule, an accumulation of fluid in the 
peritoneal cavity, and this may be made out by dulness in the flanks. 
As a rule, an examination of the blood will reveal an increased 
number of leucocytes or so-called leucocytosis, especially in the per- 
forative forms. This latter sign is not of much value unless a pre- 
vious leucocyte-count has been made or the case has been under 
constant observation, such as in forms of perforation occurring in 



GONOCOCCAL PERITONITIS. 523 

typhoid fever, for even in these cases the increase in the number of 
the leucocytes is only comparative. Thus the leucocyte-count in the 
course of typhoid fever may be 6000 to 8000 ; whereas after per- 
foration the leucocytes may not increase beyond 10,000 to 12,000. 
In other words, they may simply reach the normal limit. 

Course and Termination. — Acute peritonitis, as in the adult, 
may remain localized or may spread and become general. In the 
latter case the prognosis is very grave. If local the exudate may 
become encysted, or, if general and left to itself, may result fatally, 
or the exudate in the peritoneal cavity may rupture in the vicinity 
of the umbilicus or through the vagina or rectum. Foudroyant 
cases last two or three days and result in death. This is especially 
so of the newborn. 

Among the complications of acute peritonitis, either general or 
localized, are pleurisy, pericarditis, meningitis, pyaemia. 

Prognosis. — As stated, the general perforative forms present the 
gravest prognosis. Peritonitis of the newborn is fatal. 

Differential Prognosis. — Peritonitis, acute, localized, or diffuse, 
must be differentiated from typhoid fever. In the latter disease 
there is sometimes a severe inflammation in the vicinity of the ver- 
miform appendix, and in such cases we should be very careful that 
a perforation has not escaped our notice. 

Colprostasis, or intestinal invagination, and gastro-enteritis may 
be mistaken for appendicitis, especially in young cliildren, if the 
meteorism is great. 

Gonococcal Peritonitis. 

Gonococcal peritonitis results from an infection of the peritoneal 
cavity by the Gonococcus of Neisser. Comby recoids 7 cases of 
gonococcal peritonitis. Hunner and Harris record 7 cases. I have 
seen 2 cases. The infection takes place by way of the uterus and 
Fallopian tubes in the majority of cases. 

Etiology. — As has been stated, the gonococcus is the etiological 
factor in these cases, and the majority of recorded cases in children 
have occurred in young infants and children suffering from vulvovagin- 
itis of a gonorrhoeal nature. In my two cases this was the etiologi- 
cal factor. The symptoms are sudden pain, vomiting, fever ; or in 
other cases there results in the course of the vaginitis severe pelvic 
pain. In some cases the pain and fever are of short duration, and 
it must be surmised in these cases that the inflammation remains 
well localized to the pelvis. I have seen quite a number of these 
cases complicating vaginitis in young girls. The French have given 
the name of peritonism to these cases, thereby wishing to indicate 
their benign nature. The symptoms are so slight that one can 
scarcely believe that inflammatory reaction is present. Baginsky 
has published a case of general peritonitis resulting from gonorrhoea 



624 DISEASES OF THE DIGESTIVE SYSTEM. 

of the tubes, with an abscess-formation in Douglas's pouch. The 
gonococcus of this form of peritonitis may be associated with other 
bacteria, such as the staphylococcus. There are several forms of 
gonorrhoeal peritonitis : the general acute form, ending in death ; 
the benign pelvic form, with subumbilical pain ; and a third form 
occurring as a pelvioperitonitis with adhesions and salpingitis. 
Diagnosis must be made from appendicitis, for which it may be 
mistaken. Given a case of gonorrhoeal infection of the genitals in 
children, with sudden abdominal pain, fever, and general abdominal 
distention, the diagnosis presents no difficulties. 

Prognosis. — The French writers insist that the prognosis of 
gonorrhoeal peritonitis is benign. On the other hand, such a prog- 
nosis will depend very much on the severity of the infection. In- 
asmuch as I have personally seen three fatal cases found at autopsy 
to have been due to gonorrhoeal peritonitis complicating vulvovagin- 
itis, I cannot regard the general form of gonorrhoeal peritonitis as 
anything but a grave infection particularly fatal to children. The 
treatment of gonorrhoeal peritonitis varies according to the extent of 
the infection. If the peritonitis is localized to the pelvis it is quite 
evident that the treatment should be mostly on the lines laid down 
for the adult subject. If the peritonitis becomes general there will 
be a difference of opinion as to whether surgical interference is neces- 
sary. It is not within the scope of this work to discuss this aspect 
of the subject ; but in an excellent resume of the subject by Hunner 
and Harris the surgical interference in gonorrhoeal peritonitis is 
rather discouraged. In general peritonitis of gonorrhoeal nature 
rest in bed, hot turpentine-stupes alternating every hour with warm 
stupes, mild catharsis, liquid diet, hydrotherapy, and general medical 
treatment are rather to be advocated. 

Pneumococcal Peritonitis. 

Pneumococcal peritonitis, as has been stated, may be primary, 
and as such occurs most frequently from the second to the twelfth 
year of life. It may be secondary to pulmonary disease, such as 
pneumonia or pleurisy ; or may be primary, resulting from an infec- 
tion of the peritoneum either through the blood or the genitals. 
The frequency of encapsulation of the pus around the umbilicus 
makes the genital way of infection very probable. 

The course of the symptoms in this disease recalls that of a 
pneumonia, by its sudden onset in subjects previously in good 
health. There is a chill, followed by fever, pain, vomiting, and 
some diarrhoea. After a period of eight days there is a deferves- 
cence of the fever and abatement of the symptoms. The abdomen, 
which has been previously distended and generally painful, with all 
the physical signs found in other forms of peritonitis, remains large 
and distended, pus accumulates, the umbilicus becomes prominent, 



SIMPLE CHRONIC PERITONITIS. 525 

and in this way we have a picture resembling ascites or tubercu- 
losis of the peritoneum. I have seen a case in which the latter 
diagnosis was made. Pus may break spontaneously at the umbili- 
cus or perforate through the vagina. The disease is more frequent 
in girls than in boys, and, as has been stated, the pus has a tendency 
to become encysted and discharge at the umbilicus. The pus is of 
a creamy, yellow color, without odor. 

Michant has collected 33 cases of pneumococcal peritonitis occur- 
ring in children: 27 of these were girls; 22 were encysted, 11 
were generalized. In 27 cases the disease was primary. 

The prognosis, as a rule, is good, for in most of the cases, the 
pus being encysted, the general peritoneal cavity remains free of 
infection. In the general form, however, the prognosis is more 
grave. Of 11 cases of this form 9 died of sepsis. This form of 
peritonitis is naturally mistaken for peritonitis following appendi- 
citis. It may be distinguished from the latter, however, by its 
benign course. The pus, if it becomes encysted, may distend the 
abdomen to an enormous extent. I have seen a case in which 
the distention of the abdomen was enormous, residting in the 
obstruction of the portal circulation, with dilatation of the super- 
ficial abdominal veins. There was perforation at the umbilicus, 
and a discharge of several pints of pus, followed by recovery of 
the patient. Appendicitis is more acute in its nature and does 
not extend over such a long period of time, with the benign result, 
as seen in this form of peritonitis. 

Tuberculosis of the peritoneum can hardly be mistaken for this 
form of peritonitis. Given a distention of the abdomen by a fluid 
pointing at the umbilicus, which fluid is found to be pus, we may 
surmise that there is a pneumococcal peritonitis. A positive diag- 
nosis can only be made by bacterial examination of the pus. 

Simple Chronic Peritonitis. 

Although Henoch and Miiller have reported cases of chronic 
idiopathic non-tuberculous peritonitis, its occurrence is still a matter 
of dispute. Nothnagel, Unger, and Heubner, while not denying 
in toto its possible occurrence, insist on its extreme rarity. The 
absence in these cases of progressive emaciation is no proof of the 
non-tuberculous nature of the aifection. The absence of the tubercle 
bacillus in the abdominal exudate is of slight diagnostic value. In 
29 cases of undoubted tuberculosis of the peritoneum Herzfeld found 
the bacillus only once in the ascitic fluid. In some forms of tuber- 
culous peritonitis the nutrition may not only be good, but there may 
be no history of heredity or scrofulosis. It is manifest that under 
these conditions it is impossible to describe a disease the existence 
of which is still in doubt. 



SECTION VI. 

DISEASES OF THE EESPIRATORY, SYSTEM. 
I. DISEASES OF THE NOSE AND NASOPHARYNX. 

Examination of the nose in infants and children consists first 
in a general inspection of the organ. In this way any congenital 
deformity, particularly of the septum nasi, is noted. Some forms 
of congenital syphilis carry with them a malformation of the 
bony septum, by which the bridge of the nose is markedly de- 
pressed in very much the same manner as that of the adult. De- 
viations of the bony septum are sometimes indicated by an angular 
deflection of the organ to one or the other side. The interior of the 
nares may be inspected, as in the adult, by elevating the tip of the 
nose upward and backward, or by means of small-sized specula. 
One of the most useful methods with the author of discovering any 
obstruction in the nares, especially in the newborn and young infant, 
in whom instruments, such as specula, cannot be applied, is the 
passage of a small probe into the nares in a backward direction. 
This procedure is painless, and in the majority of cases will suffice 
to discover any swelling of the mucous membrane or bony obstruc- 
tion, if such be present. The introduction of the index finger of 
one or the other hand into the nasopharyngeal space for the purpose 
of palpating the walls of this structure has been dilated upon else- 
where in discussing adenoids. It must be reiterated here that this 
procedure should be carried out with the utmost circumspection and 
gentleness. The finger should be scrupulously clean, and the fin- 
ger-nail carefully trimmed, so as not to cause undue traumatism. 
In older children the inspection of the posterior nasal space by 
mirror, if this is possible, is much to be preferred to the digital 
examination. 

Acute Nasal Catarrh. 

This is a common afiPection of infancy and early childhood. In 
the newborn it follows as a direct result of exposure combined with 
infection, either by the lochia of the mother or uncleanliness of the 
bath water. In older infants and children acute coryza occurs 
sporadically or in epidemic form. It is apt to be seen at certain 
seasons of the year — early spring or autumn — when children are 
subjected to sudden changes of temperature of the outer air and 

527 



628 DISEASES OF THE RESPIRATORY SYSTEM. 

that of the living apartments. Infection by bacteria plays a lead- 
ing role in this disease, as in other affections of the nasopharynx. 
Infants and children are apt to be infected by adults around 
them, especially careless nurses. One child may infect the other, 
or acute nasal catarrh may usher in the acute infectious diseases, 
such as measles, bronchitis, influenza, pneumonia, pertussis, and in 
some cases cerebrospinal meningitis. One attack of nasal catarrh 
may lead to another, and thus, in the end, to chronic nasopharyn- 
geal catarrh. Some infants and children have a tendency to con- 
tract coryza upon the least exposure to a cold or dust-laden atmos- 
phere. Such infants and children are pale or rachitic or show some 
constitutional dyscrasia, such as lymphatism. 

The symptoms of acute nasal catarrh, or coryza, consist in a 
slight discharge of a serous or seropurulent secretion from the nos- 
trils. This discharge may be thin or mucoid in consistence, and 
may be small in quantity, occur in the early morning, but slight in 
amount during the day. There is, as a rule, but little or no febrile 
disturbance in mild cases. In the severer types there may be in- 
volvement of the lachrymal ducts, with slight or marked redness of 
the conjunctiva, orbital and palpebral. In the latter form there is 
lachrymation and photophobia, with or without slight febrile move- 
ment. In other cases the infants or young children are uneasy, do not 
take their usual day naps or their food, and have a slight cough. An 
inspection of the fauces may reveal but little inflammatory reaction, 
and the tonsils may be enlarged to a slight degree. As a rule, all 
these organs are drawn into the picture. In some cases conjuncti- 
vitis may be the first symptom, and the nasopharyngeal catarrh may 
follow. Restlessness in some cases and temporarily high tempera- 
ture are explained by an inspection of the drumhead of the ears, 
which may be slightly or even markedly red without bulging of that 
structure. In other words, a myringitis may give rise to a tempera- 
ture of short duration simulating a true otitis. 

Course. — As a rule, the aflection is self-limited, lasts two or 
three days, and then retrogrades ; in other cases the physician is 
annoyed at the persistence with which certain symptoms continue 
and refuse to recede with therapeutical measures. When the symp- 
toms are apparently subsiding the temperature may suddenly rise 
to 104° F., and this in the face of the most trivial physical signs. 
In such cases an inspection of the ear-drum may reveal a slight or 
marked otitis. In the nursing infant the obstruction and swelling 
in the nose may cause difficulties in nursing, and the bowels may 
show slight evidences of infection, caused by the infant swallowing 
the discharges from the nasopharynx. 

Diagnosis. — This is not difficult, but in the face of any coryza 
of an acute type the patients should be examined as to the presence 
or absence of measles, bronchitis, pneumonia, or otitis, especially if 



DISEASES OF THE NOSE AND NASOPHARYNX. 529 

a temperature of a high intermittent type is present after the second 
day of the disease. 

The prognosis is good, but it is not invariably so, as to a rapid 
termination in an uncomplicated recovery. During the early spring 
an acute coryza is not infrequently followed by an otitis, which may 
be catarrhal, purulent, or even eventually involve the mastoid. We 
should therefore not regard lightly any coryza in an infant if the 
symptoms persist beyond the third day, and other organs, such as 
the ears or bronchi, become involved. 

Treatment. — The mild forms of acute nasal catarrh in infancy 
and childhood are self-limited as to duration, and simple cleanliness 
with nursing will in most cases suffice in the treatment of the dis- 
ease. In infants the nose should be carefully cleansed with a spud 
of cotton after the morning bath, and then a drop of castor oil allowed 
to flow back into the nares. If this one application does not suffice 
to keep the nares clear of secretion, and nursing is difficult on 
account of the accumulation of secretion in the nares, this procedure 
must be repeated during the day. Mild cases need no medicinal 
treatment. If the throat is drawn into the picture, a small dose of 
2 or 3 minims of the tincture of the chloride of iron combined with 
glycerin may be given every three hours. If there is much con- 
junctivitis a saturated solution of boric acid flushed in the eye two 
or three times daily is, as a rule, efficient ; and in the subacute stages 
of the conjunctivitis a drop of a solution of sulphate of zinc, 2 grains 
to the ounce, may be instilled into the eye once or twice daily. 
The application of a copper pencil to the conjunctiva? once in the 
subacute state is advised by some, though the author thinks that 
such procedure should be carried out by the oculist. The reaction 
which follows the application of copper subsides soon, to leave the 
conjunctivae in a less angry condition. If an inspection of the 
ear-drum shows a redness without bulging of the drumhead, we 
may temporize, and if there is reason to believe that pain is 
present, a drop of warm hyoscyamus oil instilled into the ear 
once or twice daily will give relief. Marked otitis requires more 
elaborate treatment, which should be carried out by the otitic 
specialist. 

Sprays and douches are not applicable to infants and young 
children, on account of the resistance made by these patients to any 
attempts of this kind. Only older children can be taught to gargle 
or spray. Where this is possible a mild solution of listerine or 
Dobell's solution is all that is called for. I have never found it 
necessary to use the so-called coryza tablets, which contained stronger 
drugs, in children. If temperature is not present, the open air is 
certainly not contraindicated ; on the contrary, it may cut short a 
rebellious catarrh, 

34 



530 DISEASES OF THE RESPIRATORY SYSTEM. 

Chronic Nasal Catarrh. 

This is a condition found in iufants and children, as a result of 
repeated attacks of acute nasal catarrh, in a constitution luidermined 
by a pre-existent dyscrasia, such as lymphatism. In most infants 
and children this tendency to chronic catarrh is hereditary. There 
are evidences in these little ones of similar conditions elsewhere. 
Such infants and children may suffer from forms of conjunctivitis. 
Keratitis, dermal eczema, or eruptions of various kinds, anaemia, 
adenoids, nasal polypi, deviated nasal septum — may be combined 
with hypertrophy of the nasal mucous membrane. A chronic nasal 
discharge is present, and with it erosion of the nostrils and a distinct 
odor to the breath (ozsena). The tonsils in this stage are enlarged. 
Foreign bodies may set up a chronic inflammatory condition of the 
nares in children suffering from chronic catarrh ; this fact must 
never be lost sight of. 

Symptoms of chronic nasal catarrh are combined with certain 
chronic hypertrophic conditions of the throat and nasopharynx. Thus, 
very young infants, unless they are subjects of sy])hilis or adenoids, are 
not chronic sufferers from nasal catarrh. There is then a constant 
discharge from the nose and the nasopharynx. In older children, 
from five to eight years of age, the hyj^ertrophy of the nasal mucous 
membrane and the nasopharynx results in a profuse mucopurulent 
secretion in the pharynx and nose. These children are constantly 
coughing, and are subject to repeated attacks of so-called cold, the 
tonsils being enlarged, the lymph-nodes at the angle of the jaw are 
also enlarged, as also the nodes of the neck behind the sternomastoid 
muscle, and elsewhere in the body. The alse nasi are thickened and 
reveal erosions. The lips are also thickened as the result of ob- 
structed circulation. Breathing is mostly oral. An inspection of 
the fauces shows the posterior pharyngeal walls coated with muco- 
pus and studded with hypertrophied structures made up of lymphoid 
tissue called follicles. In older children these symptoms may be 
combined with symptoms of atrophic rhinitis, in which the mucous 
membrane of the nose loses its hypertrophic appearance and be- 
comes thin, atrophic, and coated with dry greenish crusts. Instead 
of obstruction there is found a wide nasal passage, and there is dis- 
tinct odor to the breath and nasal discharges. There are forms of 
chronic nasal catarrh in w^hich the above symptoms are present to a very 
mild degree. Thus, with the nasal catarrh there are enlarged tonsils 
and a few adenoids, and only an occasional odor to the breath. This 
condition is found in children who have been treated with indif- 
ferent success. The very marked cases of nasal catarrh in lym- 
phatic subjects may be combined with a conjunctivitis of a chronic type 
or granular lids and eruptions, such as ecthyma and pustular eczema 
of the chronic type, all of which indicate the presence of a dyscrasia. 



DIPHTHERITIC RHINITIS. 531 

The treatment of the above conditions are first local ; the tonsils 
and growths in the nasopharynx must either be removed or treated 
locally. The minutiae of such treatment belongs to the realm of 
nasal specialism. The local treatment must, however, be combined 
with general constitutional hygiene and treatment. The remedies 
best suited to the conditions above are discussed under the heading 
of Scrofulosis and Lymphatism. 

Diphtheritic Rhinitis. 

An apparent simple rhinitis of a catarrhal character may in a 
short time take on the characteristics of a diphtheritic process, due 
to an infection with the Klebs-Loffler bacillus. There is a profuse 
seropurulent or serosanguinolent discharge from the nose, with shreds 
of pseudomembrane, erosions of the nares, and extension of the mem- 
brane backward to the nasopharynx and downward to the larynx. 
This true diphtheria is accompanied by the glandular swellings and 
constitutional symptoms characteristic of the disease elsewhere. On 
the other hand, there is a form of rhinitis called pseudomembranous 
rhinitis, in which the disease remains fairly limited to the nose. 
There are two forms of pseudomembranous rhinitis, the truly diph- 
theritic form, in which the Klebs-Loffler bacilhis is an etiological 
factor, and the streptococcal form, both of which have a similar 
symptomatology. The form of disease to which we refer is mild in 
its course, and begins like a catarrhal rhinitis, but on the third day 
a white coating is formed over most of the inflamed area ; that is, 
on the turbinated bodies and the septum of the nose. This coating, 
which is pseudomembrane, cannot be either washed off or wiped 
away with absorbent cotton, but may be peeled off with the forceps. 
As soon as the membrane is removed, however, it reforms ; it is dead 
white and opaque, and firmly attached to the parts beneath, and, 
when detached, considerable violence must be used, and a bleeding 
surface is left. 

In some cases casts of pseudomembrane may be removed from 
the nostrils. Chapin, Bresgan, Schuler, Hartmann, and Muldenhauer 
have all described these cases. This membranous condition lasts in 
some cases from twelve to fourteen days, and though, as has been 
•intimated, some of them must be looked upon as true diphtheria, the 
prognosis is generally good. In the streptococcal cases the progno- 
sis also is good. We must never forget, however, that though there 
is in a certain proportion of cases of membranous rhinitis very few 
constitutional symptoms, and very little tendency of the disease to 
spread downward from the nasopharynx to the larynx, these cases 
should always be examined for the presence of the Klebs-Loffler 
bacillus, and if found should be treated as a diphtheritic process. 



532 DISEASES OF THE RESPIRATORY SYSTEM. 

Foreign Bodies in the Nose. 

Children are prone to put beans, buttons, pins, and foreign bodies 
of all kinds into their noses. These foreign bodies at first cause 
little disturbance ; after awhile, however, they become a source of 
pain and irritation, and, if not discovered, chronic nasal catarrh, 
ulceration, and even abscess may result. The removal of foreign 
bodies from the nose in many cases requires nothing more than ordi- 
nary skill. Some children can be taught to blow the foreign body 
out of the nostril by occluding the unobstructed nostril with the 
finger. In other cases the foreign body can be removed with the 
forceps. In the third set of cases, a scoop introduced into the nostril 
so as to hook the body posteriorly is an efficient means to remove it ; 
in other words, a bent probe or buttonhook. 

Epistaxis. 

Epistaxis is rare in the newborn, except as a manifestation 
of syphilis or sepsis. In infants and children it may be caused 
by traumatism of any kind, and is seen mostly in school children 
who have been confined in warm rooms and have developed 
nasal catarrh with or without adenoid vegetations. There may 
be in these cases small ulcers or erosions of the septum nasi. 
Epistaxis occurs in the course of acute or chronic rhinitis, typhoid 
fever, pneumonia, infectious diseases, diseases of the heart, chlorosis, 
haemophilia, scurvy, morbus maculosus, and finally, it occurs in 
young girls entering on the period of menstrual activity. It 
may occur in these subjects also as a vicarious form of menstrua- 
tion. Epistaxis, as a rule, is unaccompanied by any symptoms other 
than those of the bleeding, in drops, from the nose. In very few 
cases does this hemorrhage become alarming unless there is a history 
of haemophilia. The quantity of blood lost is often exaggerated by 
the patients, and rarely exceeds an ounce. Nasal hemorrhage may 
occur daily, or it may recur every few days or weeks, in which case 
there is always a suspicion either of traumatism, such as picking the 
nose, or a chronic nasal catarrh. Some children complain of dizzi- 
ness or vertigo preceding the attack. Others become greatly alarmed 
by the sight of blood. Children below the age of three or four years 
rarely have epistaxis except as a result of traumatism or nasal ulcera- 
tion. In some cases hemorrhage is really alarming, amounting to a 
rhinorrhagia. In these cases there is a suspicion of dyscrasia ; in 
many cases blood may during sleep flow down the posterior nares 
into the oesophagus and stomach, and after a time the clotted blood 
may be vomited or passed in the movements, thus simulating 
hemorrhage from the stomach or bowels^ and in young infants 
melaena. 



ADENOID VEGETATIONS. 533 

Adenoid Vegetations. 

It is not within the scope of this work to give more than the 
diagnostic bearings of these growths as they occur in infants and 
children. On inspection^ the posterior nasopharynx in the normal 
infant is frequently seen to be the seat of more or less adenoid 
tissue. The diseased condition is simply an exaggerated growth of 
the tissue which is normally present in this space. Clinically there 
are three distinct classes of cases that sufPer from adenoids : 

The first class comprises those in which the adenoids cause few 
or no symptoms. The children when in good health breathe 
through the nose and keep the mouth closed during sleep. They 
are peculiarly susceptible to slight colds or catarrh, and w^hen thus 
affected the tonsils enlarge, the nose becomes obstructed by secretion, 
there is difficulty in breathing, and the patient sleeps with the mouth 
open. On the subsidence of the inflammatory condition the normal 
status is re-established. The children are subject to recurrent 
attacks of tonsillitis, and with each recurrence the symptoms of 
adenoids become more marked. The patients contract obstinate 
coughs which resist all treatment, and epistaxis occurs from causes 
apparently trivial. 

The second class of cases comprises those in which, in addition to 
the enlarged tonsils, there are enlarged lymph-nodes in various 
regions of the body. The patients are pale and present all the 
symptoms of lymphatism. Their voices have a nasal intonation, 
the lips are always parted, and they sleep with the mouth open 
(mouth-breathers). 

The third class comprises the extreme cases of adenoids. The 
nasal passages are the seat of a chronic hypertrophic rhinitis, the 
tonsils are enlarged, there is obstructed breathing, and the uiouth is 
always open. The infants and children make a peculiar snarling 
sound in breathing and have a stupid look. They are not neces- 
sarily lymphatic. Many children suffering from adenoids are slightly 
deaf, and all are subject to repeated catarrhal attacks. 

Between the extremes are seen all gradations of the affection. 
Many children who suffer from adenoids are well developed and in 
other respects perfectly normal. The deformities of the chest which 
have been ascribed to adenoids can hardly be so regarded. They 
are coincidental. Many of them are due to rachitis in early life 
and to unhygienic living. To trace enuresis, chorea, and mas- 
turbation to the presence of adenoids, seems also somewhat ex- 
treme. Adenoids are an obstruction to the breathing, a menace 
to the hearing, and also a focus for repeated infections of the 
nasopharynx or the ears. These are sufficient reasons for their 
removal. 

The diagnosis of the condition is made from the above symp- 



534 DISEASES OF THE RESPIRATORY SYSTEM. 

toms, and also by digital exploration. Care should be taken that 
the finger used in exploring the posterior nasopharyngeal space is 
very clean and that the nail is smoothly trimmed. The parts should 
not be traumatized unnecessarily. The index finger passed up and 
behind the soft palate encounters soft masses of adenoid tissue which 
bleed easily and are readily crushed. They are sometimes peduncu- 
lated^ and may be attached to the roof of the nasopharyngeal space 
or to the posterior portion of the nares. Some authors have ad- 
vised the use of a shield in exploring this space. The skilful 
laryngologist prefers to use the mirror in examining these parts, 
and protests against the digital method. 

The treatment of adenoid vegetations belongs to the special field 
of the nose and throat. 

Contraindications to Operations. — The tonsils and adenoids being 
portals of infection, there are certain states in which operations in 
this region may be followed by reinfection. Thus cases of chorea 
with endocarditis, if still active, should not be subjected to operation. 
The chorea is likely to recur with greater severity, and the danger 
of a renewed heart lesion is great. Children who are in the active 
stages of endocarditis or recently recovered should not be operated 
upon. In all these cases palliative measures, such as sprays and 
douches, should be employed until the conditions above mentioned 
are thoroughly quiescent. In one case of chorea I saw an operation 
for adenoids followed in three days by a chill and high fever, endo- 
pericarditis, chorea insaniens, and death within ten days. While 
such cases are exceptional, they teach the necessity of caution in 
deciding to operate upon the adenoids in chorea and heart cases. 

Acute Retropharyngeal Abscess. 

{Idiopathic Retropharyngeal Abscess; Retropharyngeal Lymphadenitis.) 

The retropharyngeal space, according to Gillette, is the seat of 
several lymph-nodes, which are intimately connected with the lymph- 
-vessels and lymph-spaces of the tonsils, and also with the system of 
lymph-vessels of the soft palate, these being also connected with the 
deep lymph-nodes of the face and neck. Processes such as catarrhal 
angina, diphtheria, scarlet fever, measles, or any lesion of the mouth, 
are likely to involve the retropharyngeal nodes (Karewski). Some- 
times only the lymph-nodes in the median line of the retropharynx 
opposite the base of the tongue are affected. In this form the tumor 
in the midline is seen when the mouth is opened. In other cases sev- 
eral lymph-nodes are involved, and the process is then seen both as 
a swelling in the mouth and as an external swelling at the side of 
the neck. 

The swelling appears at or beneath the angle of the jaw, in front 



ACUTE RETROPHARYNGEAL ABSCESS. 535 

of or behind the sternomastoid muscles. Retropharyngeal abscess 
may occur in the following forms : 

1. Acute retropharyngeal abscess : 

a. That which points wholly in the mouth. 

6. That which points both externally and internally. 

c. That which forms a tumor chiefly external. 

2. Chronic tuberculous retropharyngeal abscess. 

3. Septic retropharyngeal abscess. 

This third class of retropharyngeal abscesses are those which 
complicate or follow the exanthemata, and which have a tendency 
to burrow downward, bursting into the mediastinum or to involve 
important structures, such as the large arteries in the neck, thus 
causing fatal hemorrhage. A few such cases occur in the literature. 

Frequency and Etiology. — Retropharyngeal abscess is peculiarly 
a disease of infancy and early childhood. The frequency diminishes 
in later childhood, the disease being rare after the fifth year. Of 
77 of my cases, 4 occurred between the first to the third month ; 10 
between the third and the sixth month ; 41 between the sixth and the 
twelfth month; 19 between the first and the fifth year, and the 
remainder after the fifth year. One infant was only one month of 
age, and in two cases the patient was two months of age. The 
figures correspond to those of Bokai. The frequency in early in- 
fancy is probably explained by the structure of the retropharyngeal 
lymph-spaces and the susceptibility of the lymph-nodes to suppu- 
rative infections at that period of life. 

Simon has described the lymphatics in the retropharyngeal region 
of infants and children as forming a small network of lymph-vessels 
and nodes on either side of the median line. This lymphatic net- 
work is situated between the superior constrictor and the aponeurosis 
of the prevertebral muscles. After the third year of life these 
lymphatics and nodes are said to disappear. This fact, as Blackader 
points out, would indicate a close connection between the time of 
activity of these nodes and the period when retropharyngeal abscess 
is most prevalent. It would help also to explain the absence of this 
form of abscess in older children and in adults who are frequently 
affected by tonsillar (quinsy) abscess. 

I have examined the pus from many of these abscesses, and found 
that it contains quite uniformly a streptococcus of the short or the 
long variety, not as a rule very virulent. It may be assumed that in 
all probability these bacteria are the essential cause of the abscesses. 
They gain access to the retropharynx either through the tonsils or 
the mucous membrane of the pharyngeal space. The abscess may 
thus be secondary to any form of inflammation of these structures. 
It occurs as a complication of simple tonsillitis, pharyngitis, influenza^ 
or any of the exanthemata. 



536 DISEASES OF THE RESPIRATORY SYSTEM. 

The symptoms of retropharyngeal abscess are not at first dis- 
tinctive. The development of the abscess is insidions. At the out- 
set there are the symptoms of ordinary tonsillitis or pharyngitis. 
The fever is high at the beginning. After the acute symptoms sub- 
side it is noticed that the lymph-nodes at the angle of the jaw con- 
tinue to be enlarged, and that the fever continues to show a remittent 
type. There is some prostration, the infant does not nurse properly, 
cries, and is frequently restless. Inspection of the throat on the 
fourth or fifth day of a tonsillitis may reveal nothing except some 
swelling or oedema of the posterior pharyngeal wall or of the 
pillars of the fauces, no tumor being visible. After an interval 
of a few days, generally on the seventh or eighth after the initial 
symptoms, it is noticed that the voice of the infant has a nasal 
quality, that the head is thrown back, and that the breathing is 
noisy and nasal. Examination shows that the lymph-nodes at 
the angle of the jaw in front or behind the stern o-mastoid are 
swollen ; inspection of the interior of the fauces shows a distinct 
swelling at the side of the pharynx pushing the tonsil and pillar of 
the fauces of that side forward. On introducing the finger a tense, 
fluctuating swelling, which may reach downward toward the larynx, 
can be felt. In other cases there is very little external swelling, 
and the internal tumor is situated nearer the median line, pushing 
the posterior pharyngeal wall forward. This swelling is covered by 
mucous membrane, is tense and fluctuating. If the tumor is allowed 
to increase in size, there is pronounced interference with the breath- 
ing. I have seen cases in rachitic infants in which the inspiratory 
sound was distinctly of a crowing character, showing incoordinate 
action of the vocal cords. These cases show great prostration and 
feebleness of pulse. 

Course. — If not treated, the abscess may press on the larynx and 
cause asphyxia, or may burst spontaneously into the larynx, suffo- 
cating the patient if it occurs during sleep, or may burst into the 
ear through the Eustachian tube and discharge externally. All of 
these results are rare if the abscess is detected in time for incision. 

The diagnosis of retropharyngeal abscess is difficult to the be- 
ginner, but is simple after the observation of one or two cases. The 
quality of the voice and the cry are so characteristic that after being 
once heard they are unmistakable. The breathing also is typical. 
The external swelling is present in most cases, and the head slightly 
retracted. Finally, digital examination should always be resorted to 
in all cases in which a slight or marked internal swelling is present. 
The index finger of the right hand is passed into the mouth and the 
posterior pharyngeal wall palpated. If an abscess be present, it 
will be apparent as a hard or tense, globular, deep or superficially 
fluctuating tumor. Care should be taken not to mistake the promi- 
nence of the body of the seventh cervical vertebrae for an abscess. 



DISEASES OF THE TONSILS. 537 

The booy tumor is deeper, as a rule, than the retropharyngeal 
abscess, and is not fluctuating. All mani})ulation should be carried 
out gently, else the abscess may burst and suffocate the patient or 
rude exploration may cause a peculiar form of collapse which some- 
times follows digital examination in this region. 

The prognosis of sim})le acute retropharyngeal abscess is good. 
Bokai lost only 4 per cent, of his cases. With early diagnosis and 
proper treatment recovery is the rule. 

The treatment of acute retropharyngeal abscess is incision. This 
varies with the nature and location of the abscess. In the majority 
of cases the abscess is near the median line, and its wall is just 
beneath the surface of the mucous membrane. An internal incision 
will then afford immediate and permanent relief. In other cases the 
abscess is at one side and internal, and may also be safely incised from 
within. In making an internal incision the followiup; method should 
be pursued : the child is wrapped in a blanket and held upright in 
the lap of the nurse, facing a good light. An assistant steadies the 
head from behind. The tongue is depressed with a tongue-depressor, 
and a bistoury, with the edge guarded by rubber plaster, leaving 
only a half inch of the tip exposed, is plunged into the most promi- 
nent part of the tumor. When the pus escapes, the incision is 
enlarged from above downward. The instrument should not be 
directed toward the side of the neck, for fear of wounding a vessel. 
As soon as the pus escapes freely the head of the infant is thrown 
forward and the pus allowed to drain into a basin, pressure being 
made from without, on the side of the neck. The internal incision 
should be made as rapidly and as gently as possible. I have seen 
death result within a few hours from aspiration of pus in a case in 
which an abscess burst as a consequence of rough digital explora- 
tion. If necessary, the incision may be enlarged with a dressing- 
forceps. In some cases the wound should be prevented from clos- 
ing by introducing the forceps daily. 

There is another class of cases in which the deep cervical glands 
at the side of the neck are involved and the abscess points partly 
internally and partly externally. In these cases it is unsafe to 
incise from within, nor is complete relief afforded by so doing. 
The abscess should be approached from without through a careful 
dissection by a skilled surgeon. The tuberculous abscess is due to 
spinal caries, and is best opened and drained from without, as are 
also septic abscesses. 

II. DISEASES OF THE TONSILS. 

The tonsils are really lymph-nodes, as has been shown by Stohr 
and Hodenpyle. In severe forms of inflammation they are en- 
larged, and the so-called crypts become plugged with bacteria and 



538 DISEASES OF THE RESPIRATOHY SYSTEM. 

the products of inflammation (leucocytes, fibrin, serum). The crypts 
appear at the surface of the tonsil as yellowish specks. A catar- 
rhally inflamed tonsil may not show them at the surface, because the 
products of inflammation do not coagulate, and are thus thrown off 
more readily. There is nothing specific about a lacunar or follicu- 
lar amygdalitis. It is only a clinical picture of the large class 
of catarrhal inflammations, in all of which the crypts and the 
tissue of the tonsil are infiltrated with inflammatory products. 

Acute Follicular Amygdalitis. 

{Acute Catarrhal Tonsillitis; Acute Lacunar Amygdalitis ; Catarrhal Angina.) 

Acute follicular amygdalitis is an infectious disease, communi- 
cable either through the secretions or by direct contact, as in the act 
of kissing. It occurs both as a primary and as a secondary aflection. 
As a primary affection, it occurs at all periods of infancy and child- 
hood. It was formerly taught that follicular amygdalitis was rare 
in infants. This is scarcely true. Of 1284 cases of lacunar amyg- 
dalitis, 333 occurred in infants under the age of twelve months, and 
76 from the first to the fifth month ; of the latter, only 5 occurred 
in the first month. It is frequent in children from the second to 
the fourth year, but is more common after than before the fourth 
year. The tonsils are secondarily involved in the exanthemata — 
scarlet fever, measles, and varicella — and in parotitis, influenza, pneu- 
monia, and pertussis. In all these affections they are red, swollen, 
and in some cases present the appearance seen in the typical lacunar 
type of the disease. 

Etiology. — The predisposing causes of catarrhal tonsillitis or 
lacunar amygdalitis are exposure to cold, traumatism, and the swal- 
lowing of corrosive or irritant substances. The exciting causes of 
follicular or lacunar amygdalitis and catarrhal amygdalitis are the 
Streptococcus pyogenes, the Staphylococcus pyogenes, and the pneu- 
mococcus. The diplococcus described by Roux is also found in the 
tonsillar crypts. 

Symptoms. — The affection rarely begins with a chill. The 
infant is restless, peevish, and wakeful at night ; it breathes rapidly, 
and there are high fever and marked prostration. Nursing is in- 
terfered with, not only on account of the pain in swallowing, but 
because in the majority of cases there is more or less rhinitis 
present. As a rule, the bowels are disturbed as a result of swallow- 
ing infectious secretions from the mouth with the food. The action 
of the bacteria in the gut is manifested in green stools, which are 
frequent and watery. Inspection of the throat should be conducted 
with patience and in a good light. The tonsils, normally very small, 
are seen to be enlarged and studded with Avhitish or yellowish-white 
points. The lymph-nodes at the angle of the jaw may be enlarged. 



ACUTE FOLLICULAR AMYGDALITIS. 539 

In older infants and children the tonsils are enlarged, and the 
crypts plugged with inflammatory products. The surface of the 
tonsils is covered with mucopurulent exudate, or there may be a 
small necrotic, ulcerated area in one of the tonsils. The neighboring 
structures, such as the uvula, the pharyngeal mucous membrane, 
the pillars of the fauces, and even the larynx, may share in the 
catarrhal inflammation. The lymph-nodes at the angle of the 
jaw may be enlarged. The fever, as a rule, is high at first, ranging 
from 104° to 105° F. (40° to 40.5° C.) or above. The pulse is 
correspondingly rapid, and the respirations may be increased in fre- 
quency. 

The duration of a typical case of primary tonsillitis varies. As 
a rule, the temperature remains high for two or three days, with 
daily remissions. It then subsides and the patient convalesces. In 
some cases the temperature continues high for five or ten days, and 
then drops. In all of these cases there is some latent or apparent 
complication, such as retropharyngeal abscess, otitis, or, as has been 
recently pointed out by Packard and others, an insidious endocarditis. 
When otitis supervenes the tonsillar affection subsides. The fever, 
however, continues, with daily remissions. As a rule, infants and 
young children do not indicate the existence of pain in the ear. The 
patient is restless at night, and wakes with a start or in a peevish 
mood. In many cases the otitis can be diagnosed only by exclu- 
sion. In other cases the temperature continues high for a week or 
longer, reaching 103.5° F. (39.7° C.) during the day. The infant 
seems weaker, the tonsils are not enlarged or severely inflamed, the 
pulse is accelerated, and the respirations may number 40. In such 
cases the lungs show no sign of involvement, but careful examina- 
tion of the heart will often reveal the presence of a systolic murmur 
at the apex and a slight increase of the area of cardiac dulness 
beyond the nipple. These are the so-called rheumatic cases. Fre- 
quently the urine shows a trace of albumin. In rare cases it con- 
tains in addition to the albumin elements pointing to parenchymatous 
irritation of the kidney. I saw a case recently, in a child six years 
of age, in which after a mild attack of tonsillitis there were a 
few casts, blood-cells, and a small amount of albumin in the urine. 
Months elapsed before the urine ceased to show evidences of the 
nephritis. In these cases the albuminuria may assame the so-called 
cyclic character. 

The prognosis of simple catarrhal tonsillitis is good, recovery 
taking place in a few days. On the other hand, tonsillitis is not 
the simple entity formerly supposed. In infants and children this 
is especially true. The physician should be watchful for possible 
complications and sequelae, such as otitis, retropharyngeal abscess, 
endocarditis, and nephritis. 

The diagnosis of tonsillitis is usually a simple matter. If an 



540 DISEASES OF THE RESPIRATORY SYSTEM. 

infant refuses the breast and the temperature is elevated, the throat 
should be carefully inspected. It is good practice to make a bac- 
teriological culture with the secretions from the throat, even though 
the appearances are not diphtheritic at the first visit (for technique, 
see section on Diphtheria). 

The treatment of acute tonsillitis is symptomatic. Sponging 
with cold water or water at 85° F. (29.4° C.) containing a dash of 
alcohol, will lower the temperature. A dose of quinine should be 
given twice daily, and if the lymph-nodes at the angle of the jaw 
are enlarged, cold applications should be made externally. Sprays 
are not required unless there is a harassing cough. DobelFs solu- 
tion sprayed three times daily will relieve that symptom. In 
nursing infants the number of feedings by the breast or bottle is 
reduced. If there is disturbance of the bowel, a teaspoonful of castor 
oil or grain J (0.03) of calomel, given twice daily, will empty the 
bowel. The infant is then dieted on albumin-water or barley- 
water, or a solution of acorn cocoa or beef-juice and barley-water, 
until the intestinal irritation has disappeared. A return to a 
milk diet may be made as soon as the movements become normal. 
Small doses of ferric chloride have a beneficial effect on older 
children. In mixture form it is an excellent local application 
to the tonsils. The custom of giving potassium chlorate in this 
mixture is now generally abandoned, the drug being highly irri- 
tant to the kidneys. In nursing infants ferric chloride causes 
diarrhoea. For this reason it should not be administered to them 
for long periods. 

Herpes of the Tonsils. 

Herpes of the tonsils are small vesicular formations seen on the 
anterior pillars of the fauces, just in front of the tonsils. They 
occur in a number of slight febrile conditions, may accompany an 
angina of a simple type, and are part of the clinical picture of aph- 
thous stomatitis. The vesicles burst, leaving yellowish ulcerations 
of the size of a pin's head and surrounded by a pink areola. They 
heal without treatment after a few days. 

Ulceromembranous Tonsillitis or Angina. 

{Associated with the so-called Fusij'orm Bacillus of Vincent.) 

This is a peculiar affection occurring in cliildren. At first one ton- 
sil is affected, generally the right. After a few days the affection 
may spread to the other tonsil. Most of the cases I have seen were 
unilateral. In addition to the tonsillar ulcerations, a stomatitis of 
an ulcerative type is often present, and there may be ulcers on the 
tongue, cheeks, and gums. 



ULCEROMEMBRANOUS TONSILLITIS OR ANGINA. 541 

The size of the tonsillar ulcer varies frora that of a lentil to an 
involvement of a greater part of the tonsil, the shape of the ulcer- 
ation being irregular, and its character rather of a chancroidal type. 
It has a worm-eaten base with sharp, overhanging edges, which may 
be slightly raised above the surface of the tonsil. The rest of the 
tonsil is but very slightly inflamed. The color of the ulceration is 
a yellowish-green gray, or dirty brown, and from the first it ap- 
pears as though the base of the ulcer were covered by membrane. 
The depth of the ulcer is quite considerable, varying from i to 
1 inch. The submaxillary glands may be enlarged, or the lymph- 
nodes communicating with the tonsil at the angle of the jaw may 
also be enlarged. 

Etiology. — The etiology of ulceromembranous tonsillitis or 
angina has been carefully worked out by Friihwald, Vincent, Le- 
raoine, Abel, and in our own country by Sobel, Herrman, and 
others. This form of tonsillitis is caused by a bacillus, described 
more particularly by Vincent, and a spirillum. The bacillus is 
about twice as long as the diphtheria bacillus, is pointed at both 
ends ; in other words, fusiform. Some of the bacilli are bent into 
crescent shapes. They vary in size, some being larger and thicker 
than others. The spirilla are long, corkscrew-like, with wide curves. 
They also vary in size, the larger and thicker ones staining more 
deeply. The bacilli and spirilla are motile. 

Symptoms. — This affection can scarcely be classed as one of the 
more serious affections of the tonsil, although at times of a subacute 
chronicity. The children are brought to the physician with a history 
of an ordinary sore throat, and when examined this ulcer of a deep- 
spread, pseudomembranous type is found on one or the other tonsil. 
The appearance is as if an irregular hole were punched out of the 
tissue of the tonsil. There is no spreading of membrane, nothing 
resembling diphtheria. There is slight fever, rarely higher than 
103° or 105° F. The symptoms at the outset are so mild that when 
the patient is brought to the physician the ulceration has taken place. 
In those cases in which there is accompanying stomatitis on the 
tongue, gums, or buccal mucous membrane, there is also foetor of the 
breath. In some cases there may be pallor of a distinctly septic 

Diagnosis. — The clinical diagnosis must be made from that of 
diphtheritic ulcers, resembling very much what has just been de- 
scribed. Henoch and the author have described ulcers of a truly 
diphtheritic character very much resembling ulceromembranous 
angina. The only test is that of the culture-tube or the smear. 
An ordinary microscopical smear stained from the base of the ton- 
sillar ulcer will reveal its true character if of the Vincent type. If 
the bacillus and spirilla are not evident at once, we should make a 
culture for the diphtheria bacillus. 



542 DISEASES OF THE RESPIRATORY SYSTEM. 

The prognosis is invariably good ; although in some cases the 
course of the disease is apt to become subacute, on account of the 
difficulty of reaching the base of the ulcer with remedies. Some 
cases may last as long as three weeks ; others recover within a few 
days. Lemoine relates one case which lasted seventy days. 

The treatment is much the same as that of an ordinary ton- 
sillitis. The tincture of the chloride of iron is given in doses of 
from 3 to 5 minims, combined with glycerin and water, every three 
hours. The base of the ulcer may be touched daily either with 
Lugol's solution or a 10 per cent, solution of nitrate of silver. 

III. DISEASES OF THE LARYNX. 

Acute Catarrhal Laryngitis. 

(Catarrhal Croup; Spasmodic Croup; Spasmodic Laryngitis ; Pseudocroup.) 

Etiology. — Exposure to cold or wet are predisposing causes. 
Like the majority of catarrhal inflammations of the respiratory pas- 
sages, acute catarrhal laryngitis is due to the invasion of bacteria. 
It occurs as a primary affection, and in a modified form is met with 
secondarily in measles and influenza. The classical form of 
" croup" is a primary affection, and is most common from the 
second to the fifth year. It is also seen in very young infants. One 
attack predisposes to others. 

Symptoms. — Catarrhal croup or catarrhal laryngitis is an affec- 
tion that causes much concern to mothers when a first attack develops 
without warning. During the day the infant may have had a mild 
coryza with a slight elevation of temperature. Toward evening a 
croupy cough, accompanied by croupy breathing or voice, suddenly 
develops. In some cases the symptoms remain mild, and only the 
cough disturbs the patients. They breathe freely, and dyspnoea is not 
marked. In other cases the infant or child goes to sleep free from 
alarming symptoms. Coryza may have been present unnoticed 
during the day. During the night the patient awakes with a croupy 
cough, which rapidly becomes worse. The breathing is noisy (croupy), 
and may be heard in an adjoining room. The cough is especially 
terrifying. The patients are restless, and cry during the paroxysms 
of coughing. In some cases they sit upright and gasp for breath. 
The face is pale and wet with cold perspiration. Fever may be 
slight or marked and may reach 104° F. In the majority of 
cases the dyspnoea is real ; there is drawing inward of the 
suprasternal region and the peri-pneumonic groove at the epigastrium. 
Toward morning the dyspnoea, cough, and croupy breathing subside, 
and the patients fall asleep, worn out with the night's suffering. 
The next day the patients are apparently well, with the exception 
of a slight or marked croupy cough, coryza, swollen tonsils, with 



DISEASES OF THE LARYNX. 543 

redness of the pharynx. For two or three successive nights or 
days there may be a repetition of the attack. This condition 
should be differentiated from laryngismus stridulus. In the latter 
there is no fever, the breathing is stridulous during only a short 
spasmodic attack, and there is no croupy cough. On the other 
hand, pseudocroup may occur in children who are rachitic and the 
subjects of laryngismus. There are forms of diphtheritic laryn- 
gitis without the formation of membrane, which in their symptoma- 
tology are identical with the form of laryngitis above described. 
This is true in very young infants and in children above five years 
of age. A culture-test is the only certain mode of differentiating 
the affections. The pathological condition giving rise to pseudo- 
croup is believed to be a swelling of the mucous membrane beneath 
the vocal cords. 

Diagnosis. — The diagnosis is not difficult except in cases in 
which the croupy cough, breathing, and stridor increase as the day or 
night wanes and no relief comes to the sufferer. In other cases the 
obstruction to the breathing in the larynx increases as in truly mem- 
branous cases. Only a i^epeated culture will reveal the nature of 
such an affection, because one culture may be negative even in a 
truly diphtheritic case. In the severe forms of '^ croup,'' in the face 
of increasing laryngeal obstruction^ the interests of the patient are 
best subserved by assuming the presence of a diphtheritic process 
until the bacteriological culture proves the contrary to be the case. 

The prognosis is good. I have never met a fatal case of non- 
diphtheritic catarrhal croup. On the other hand, many of these 
cases are due to a grippal infection. Such an infection may carry 
in its train complications, such as bronchopneumonia or ear affections, 
which may endanger the life of the patient. 

Treatment. — The patient is isolated, and placed under a tent im- 
provised over the crib. The tent is kept filled with steam generated 
by any of the devices for croup in the market (croup-kettle) ; the 
steam is saturated with turpentine, thymol, or benzoin. At in- 
tervals of an hour 10 grains of calomel are sublimed underneath the 
tent until the croupy cough and breathing abate. To relieve the 
laryngeal spasm, especially if there is a temperature, antipyrin, in 
doses of a grain to every year of the age, is efficient and induces 
rest and sleep. Antimony (y^o- grain) combined with ipecacuanha 
(^_ grain) may be given every two hours, or 20 drops of the syrup of 
ipecac every two hours until emesis occurs. Turpeth mineral is given 
by some to induce vomiting. I do not use the drug. If symptoms of 
progressive stenosis set in, intubation is justified, and in localities 
where bacteriological examinations are not feasible, diphtheria anti- 
toxin should be administered, lest a membranous diphtheritic process 
be overlooked. I have seen cases, however, which developed cyanosis 
recover without intubation. It is questionable whether it is jus ti- 



544 DISEASES OF THE RESPIRATORY SYSTEM. 

fiable to allow the patient to suffer when such a simple means, as the 
introduction of a tube in the larynx, is feasible. The application of 
counterirritants to the larynx is of questionable utility. The same 
may be said of the application of heat or cold externally. 

(Edema Glottidis. 

{Submucous Laryngitis ; Phlegmonous Laryngitis.) 

Definition. — This is a serous or sero-purulent infiltration of the 
submucous cellular tissue of the region of the upper larynx, or glottis, 
and the aryepiglottic folds. 

Etiology. — There are two forms — first, the simple serous infil- 
tration of the glottis ; and, second, the inflammatory infiltration, the 
so-called phlegmonous laryngitis, in which the submucous connective 
tissue is involved. The serous form is secondary to and accompanies 
acute and chronic nephritis, infectious diseases, scarlet fever, variola, 
syphilis, typhoid fever, inflammation or ulceration of the structures 
adjacent to the larynx, especially of an erysipalatous nature. 

The second form, the phlegmonous laryngitis, is due to trau- 
matism, such as the direct inhalation of steam, customary among chil- 
dren of the tenements when playing in the kitchen ; chemicals, 
foreign bodies, and injuries. 

Morbid Anatomy. — In the serous form of oedema glottidis the 
submucous tissue is tense, infiltrated, pale or yellowish red ; there is 
swelling of the upper laryngeal area. In the phlegmonous form the 
mucous membrane is dark red, swollen, covered with pus, and there 
may be ulceration of the mucous membrane of the larynx and vocal 
cords. 

Symptoms. — In the forms accompanying nephritis and the in- 
fectious diseases, the first symptoms to appear are those of stenosis 
of the larynx. In the traumatic form of phlegmonous laryngitis 
with consequent oedema of the glottis, especially in cases in which 
steam has been inhaled by children, there is pain in the mouth and 
pharynx, dysphagia, and dyspnoeic attacks. Inspection shows the 
mucous membrane of the mouth and pharynx to be inflamed and the 
tissues of the epiglottis swollen ; and an inspection of the larynx 
reveals swelling of the false vocal cords and narrowing of the rima 
glottidis. 

The course of the disease depends on the nature of the primary 
affection. The milder cases, especially those accompanying acute or 
chronic nephritis, may retrograde. Other cases, especially the trau- 
matic, if unrelieved may result in fatal suffocation. 

The prognosis must depend on the prognosis in the first form of 
the primary affection, and in the traumatic and phlegmonous forms 
of laryngitis the prognosis of the oedema glottidis depends on the 
severity of the disease, 



TUBERCULOSIS OF THE LARYNX. 545 

The treatment must consist, if a nephritis be present, in the treat- 
ment of the nephritis, and we must not forget that intubation or 
scarification in children is in most cases ineifectual. Intubation is 
apt to be ineflPectual on account of the additional traumatism caused 
by the attempts at introduction of a tube, with consequent formation 
of false pockets. If the symptoms are such that suffocation is im- 
minent, tracheotomy offers the simplest and safest means of relief. 

In many cases of oedema of the glottis, especially of the milder 
type, a small dose of the opiates will quiet the patient and have a 
tendency to relieve the apparent dyspnoea until such time as the 
symptoms of the primary disease retrograde. Especially difficult of 
treatment will be the secondary cases, with phlegmonous disease in- 
volving structures adjacent the larynx, such as angina Ludovici. In 
these cases the swelling of the structures may be so great as to make 
tracheotomy a very difficult operation. Intubation in these cases is 
scarcely to be thought of. 

Syphilis of the Larynx. 

This affection is rare in infancy and childhood, inasmuch as it 
accompanies the later forms of syphilis. The seat of election of 
this disease is the epiglottis, where ulcers and condylomata are 
formed. The structures are thickened, inflamed, covered with white, 
diffuse patches, and the same changes are seen in the interior of the 
larynx as on the aryepiglottic folds. Cicatrices may form and cause 
marked symptoms of stenosis. Ulcers are seen on the back of the 
tongue and on the vocal cords. Gummatous infiltrations may form, 
ulcerate, and lead to inflammation of the cartilages and necrosis of 
these structures, causing stenotic symptoms. 

The diagnosis depends on a discovery of syphilitic lesions else- 
where. 

The prognosis depends on how soon anti-syphilitic treatment can 
be in augurated before ulceration and cicatrization results. 

The treatment of this affection consists in applying the anti- 
syphilitic remedies ; and when stenosis of the larynx occurs as a re- 
sult of cicatrization and contraction of the structures of the larynx, 
intubation, according to O'Dwyer, offers the most effective means 
of relief. 

Tuberculosis of the Larynx. 

This is very rare in infancy and childhood, and is more common 
toward the age of puberty. It can affect any part of the larynx, 
causing hoarseness. It is rarely primary, being, as a rule, secondary 
to tuberculosis of the lungs or other organs. 

The treatment belongs in the realm of special laryngeal v/ork. 

35 



546 DISEASES OF THE RESPIRATORY SYSTEM. 

Growths in the Larynx. 

The most common tumors found in the larynx are papillomata, 
granulomata, and fibromata. Malignant tumors are rare. Fully 
25 per cent, of the papillomata are congenital, and manifest them- 
selves from birth by symptoms of hoarseness and troubled cough. 
A frequent case of granulomata and papillomata of the larynx is re- 
current laryngitis and operations upon the larynx, such as intu- 
bation or tracheotomy. 

Symptoms. — Tumors of all kinds cause hoarseness, accompanied 
by paroxysms of coughing with difficulty of respiration due to a 
certain amount of stenosis, varying according to the size of the 
tumor. Some of these tumors may give rise to symptoms of suf- 
focation. The granulomata which follow tracheotomy cause symp- 
toms of asphyxia after the removal of the tube. 

In addition to the above symptoms, there are evidences, in all 
cases of tumor of the larynx, of catarrhal inflammation of the 
neighboring structures. 

The treatment of growths in the larynx belongs to the realm of 
throat surgery. 

Foreign Bodies in the Larynx. 

During play children often aspirate bodies of all kinds into the 
larynx, and the symptoms caused depend very much upon the size 
and shape of the body aspirated. In rare cases the body lodges iu 
the larynx, and may cause iustant death by suff'ocation. Smaller 
bodies lodging in the ventricle of the larynx may cause attacks of 
dyspnoea, which subside when the patient takes the recumbent posi- 
tion ; but even these small bodies may cause instant death if they 
once lodge in the rima glottidis and close the opening of the larynx. 
Some of these bodies may after a time lodge in the bronchi and cause 
pneumonia. 

The prognosis depends upon the nature of the body and the pos- 
sibility of dislodging it. 

Treatment. — If the body is small, it may sometimes be dis- 
lodged by standing the patient, as it were, on the head. It theu 
emerges into the larynx and is coughed out. If such is not possible, 
it is best to locate the body by means of a radiograph, and then 
attempt its removal by surgical means. 

IV. DISEASES OF THE BRONCHI. 

Acute Simple Bronchitis. 

Bronchitis, acute and simple, is an affection of the larger and 
medium-sized bronchi. In very young infants the disease is apt 
to be very severe and to attack the smallest bronchioles ; it is then 



ACUTE SIMPLE BRONCHITIS. 547 

called capillary bronchitis. A capillary bronchitis is really a bron- 
chitis in which there is a certain amount of peribronchitic pneu- 
monia. Acute bronchitis may occur at any period of infancy or 
childhood. It is, however, less common before the sixth month 
of infancy than during the period up to the third year, when its 
frequency diminishes. 

Causation. — Bronchitis may be caused by an exposure to cold 
or wet or by traumatism to the mucous membrane of the air-pass- 
ages through the inhalation of dust or irritating vapors. It occurs 
in the acute infectious diseases, such as malaria, scarlet fever, 
measles, rotheln, varicella, typhus and typhoid fevers, and frequently 
complicates pneumonia of the lobular or lobar type. Kachitis and 
syphilis predispose to attacks of bronchitis. The bronchitis of 
heart disease or nephritis should be regarded as of a different class. 

Pathology. — The bronchi may be filled with a mucous, serous, 
purulent, or mucopurulent secretion, which is secreted by the epithe- 
lium of the mucous membrane and the mucous glands in the wall 
of the bronchi. In recent acute bronchitis the mucus is quite 
abundant. In the exudate on the mucous membrane of the bronchi 
and in the lumen, epithelial cells, leucocytes, and sometimes red 
blood-cells are found. The structure of the mucous membrane is 
infiltrated with small round cells to a greater or less degree. In 
some places the epithelial lining of the bronchi may be raised by 
exudate ; in others there may be loss of the superficial epithelium. 
If the bronchitis lasts any length of time, there may be atrophy of 
the structures of the mucous membrane. In the severer forms of 
bronchitis which affect the smaller bronchi the peribronchitic con- 
nective tissue is infiltrated with small round cells. In these cases 
there is an inflammatory exudate in the surrounding alveoli of the 
lung. There is then peribronchitis or bronchopneumonia. 

Symptoms. — In some cases the infant or child suffering from 
acute bronchitis will have a simple angina as an initial symptom. 
There is mild redness of the fauces with a slight rise of temperature 
which may last a day or more. The cough which was present at 
first persists, and there may be slight disturbance of the bowels, the 
movements being green and containing large curds of undigested 
matter. 

The cough may in aggravated cases give rise to occasional at- 
tacks of vomiting, especially immediately after nursing ; at other 
times the coughing spells may cause the patient to cry. There 
is evidently pain, especially in the cases of bronchitis affecting 
the larger bronchi. The infant sometimes suffers from great 
difficulty in expelling the accumulated secretion. The attacks of 
coughing closely resemble those seen in old people who suffer from 
bronchitis. In many cases the infant or child is quite comfortable 
in the intervals between the coughing spells. In others the respira- 



548 DISEASES OF THE RESPIRATORY SYSTEM. 

tions are iocreased, and there may for some days be a slight evening 
rise of temperature, the patient showing signs of being seriously ill. 
In very young infants who are rachitic there may be a distinct 
drawing in of the sides of the chest and of the peripneumonic groove 
at each respiration. In cases of severe involvement of the smaller 
bronchi, there may be slight cyanosis of the lips and pallor of the 
surface. 

In the severer forms of bronchitis, especially of the grippal 
varietv, there is a distinct rise of temperature for several davs. It 
may rise to 102°-103° F. (38.8°-39.4° C), or even higher,\vith a 
corresponding increase in the number of respirations and the pulse- 
rate. In weak and very young infants there may be little or no 
cough. The infant lies in a soporose state, does not nurse well or 
refuses the breast. Older children may run about and play while 
suffering from bronchial trouble ; severe bronchial disturbance may 
appear to have little effect on the general health. Expectoration is 
very exceptional ; a frothy mucus collects about the lips of young 
infants after an attack of coughing. In older children it may be 
very difficult to collect sputum, even if they are old enough to un- 
derstand the necessity of expectorating the secretion. The conclusion 
has been that children swallow the expectoration ; it is more rational 
to suppose that the efforts at coughing are not equal to raising any 
considerable quantity of secretion or that the amount of secretion 
in bronchitis is not so great as has been generally supposed. In 
many cases the cough is severer at night than during the day, but 
children cough and fall asleep immediately afterward, and therefore 
do not lose much rest. I have never met with a simple acute bron- 
chitis ushered in by a chill or convulsion. I have, however, seen 
severe forms of bronchitis cause petechial extravasations on the 
skin, similar to those seen in pertussis. The petechise are apt to 
occur about the forehead and eyes of very weak infants. 

Physical Signs. — In mild cases the respirations may be slightly 
above the normal ; in severer cases there are signs of dyspnoea and 
the respirations are increased in number. In very severe forms the 
peripneumonic groove may be drawn inward with each respiratory 
act. In capillary bronchitis the lips may show some cyanosis, the 
surface may be pale, and the finger-tips slightly cyanosed. 

Palpation. — If the palms of the hands are placed in front and 
behind the chest, the so-called rhonchal fremitus may be elicited. 
The vibrations caused by accumulated secretion in the large and 
small bronchi give a sensation resembling that felt in stroking a 
purring cat. 

Percussion. — In simple acute bronchitis, percussion may elicit 
nothing abnormal. If infants have suffered from repeated attacks 
of bronchitis, the note may, owing to a slight emphysema, be hyper- 
resonant or vesiculotympanitic. In severe forms of capillary bron- 



ACUTE SIMPLE BRONCHITIS. 549 

chitis there may be areas of peribronchitic pneumonia or broncho- 
pneumonia, over which careful percussion will detect slight dulness 
with a resonant note. 

Auscultation. — In a vast number of cases, bronchitis at the outset, 
gives on auscultation nothing but a rude respiratory murmur which 
is more markedly puerile than is normal. As the secretion accumu- 
lates there will be sonorous, sibilant, and subcrepitant rales, and also 
sonorous breathing. In the form called capillary bronchitis, with 
the subcrepitant rales there will be rales of much finer quality, re- 
sembling crepitant rales. The latter, which are unmistakable, are 
heard on inspiration, and appear to indicate areas of peribronchitic 
pneumonia. In newly born and weakly infants there are, in this 
form of bronchitis, areas in which the air is not heard to enter the 
lungs (atelectasis). 

The treatment of simple acute bronchitis should be supporting 
and expectant. If the cough is harassing, a mild opiate mixture in 
combination with a small quantity of ipecac may be given. The 
following prescription has been found useful : 

R Tinct. opii camph 5j (4.0). 

Syr. ipecacnanhae ir^ xxxij (2.0). 

Syr. tolutani Jij (60.0). 

Sig. Teaspoonful every tliree hours. 

The patients are allowed to be in the open air in fine weather, and 
the room should be Avell ventilated at night. In cases in which there 
is great relaxation of the mucous membranes, a dose of strychninse 
sulph., grain -^--^ (0.0003), may be given three or four times daily. 
The child is kept warmly clad, and wool is worn next the skin. 
Douching with cold water is to be avoided in acute cases. The oil- 
silk jacket may be worn, but it has no special superiority to warm 
clothing. Applications of oil to the chest are of no value. The 
drugs of the coal-tar series (antipyrin or phenacetin) should not 
be used, except that one dose may be given at the very outset to 
relieve restlessness or headache. The bowels should be relieved by 
means of calomel or a saline cathartic. 

In the subacute stage, syrup of ferric iodide may be given as a 
tonic for the mucous membrane. In very rachitic infants and chil- 
dren, cod-liver oil is indicated. 

The treatment of so-called capillary bronchitis approaches very 
closely that of bronchopneumonia. The heart should be supported. 
Digitalis in the form of tincture is the most useful remedy. Strych- 
nine, caffeine, camphor, and musk in form of powder, all have here 
their legitimate sphere. 

The temperature, as a rule, needs no treatment. With older chil- 
dren, if the secretion is very profuse, carbonate of guaiacol is exceed- 
ingly useful and gives much relief. 



550 DISEASES OF THE RESPIRATORY SYSTEM. 

Fibrinous or Plastic Bronchitis. 

This is a form of bronchitis in which membranous masses or 
fibrinous exudate are coughed up at intervals. These masses may 
have the exact shape of the bronchi, or may consist of shreds or 
bands of membrane. 

Etiology. — Bronchitis of this form complicates diphtheria and 
pneumonia, and also occurs in the acute infectious diseases — -measles, 
scarlet fever, tuberculosis, erysipelas, typhus and typhoid fevers. 
It is found in diseases of the heart and lungs, and may result 
from traumatism through the inhalation of poisonous gases. The 
above are the secondary forms ; the primary form of fibrinous 
bronchitis is obscure in its etiology, and is rare in infancy and child- 
hood. 

Morbid Anatomy. — The casts which are coughed up are cylin- 
drical in shape and branched in the form of the larger and smaller 
bronchi. The larger ones may be hollow and cylindrical, while the 
smaller ramifications may be solid or thready. In other cases the 
whole cast is solid ; small air-bubbles may be confined in the fibrin- 
ous cylinders. The casts may be 10—12 cm. in length, the extremi- 
ties being nodular, thready, or fiat. Under the microscope the casts 
are seen to be formed in layers ; in the centre of the oldest layers are 
found epithelium of the bronchi, leucocytes, and bacteria. Spirals 
formed of fibrin are occasionally found in the expectorated masses, 
especially in the diphtheritic, pneumonic, and the so-called idiopathic 
cases. 

Symptoms. — Attacks of Dyspnoea. — This form of bronchitis is 
characterized by attacks of dyspnoea and coughing. During the 
attacks clots of purulent fibrinous masses are expectorated, some- 
times with a slight amount of blood. In spite of the expectoration 
of blood there are no signs of tuberculosis. The presence of blood 
is probably caused by the detachment of the membranous casts from 
the walls of the bronchi. The expectorated masses may contain 
asthma crystals. In the intervals between the attacks, there may 
be symptoms of an ordinary bronchitis with mucopurulent expecto- 
ration, or there may be absolute freedom from symptoms. 

The cough, which is present during the attacks, may be accom- 
panied by a snarling or fluttering sound. 

Cyanosis may be present during the attack to a marked degree or 
may be absent. 

Fever is present in the acute form, but has no special character- 
istics. 

Splenic tumor may be present. 

The physical signs of bronchitis may be present with rales of 
all kinds. If the membranous masses hang detached in the bronchi, 
a snarling or flapping sound may be heard on auscultation. 



EMPHYSEMA AND CHRONIC BRONCHITIS OF THE LUNGS. 551 

The general condition of patients in the intervals and during the 
attacks varies greatly. In some cases it is fairly good. 

Complications. — A tuberculous bronchitis or pneumonia may be 
a complicating condition. 

The diagnosis is made from the presence of the fibrinous casts. 

The treatment has thus far been very unsatisfactory ; mercury, 
and also inhalations and sprays of all kinds have been tried by 
Biermer in the acute cases. Iodide of potassium is of value in the 
intervals. If diphtheria is present, the antitoxin is given. 



Emphysema and Chronic Bronchitis of the Lungs. 

Frequency. — Emphysema is a condition frequently seen post- 
mortem in the lungs of infants and children (Steffen). No dis- 
ease of the lungs runs its course without causing some emphy- 
sema. The condition is much more common in children than in 
adults, because it is favored by the peculiar structure of the lung 
during early life. Most of the forms of emphysema of the lungs 
of infants and children retrograde, allowing the lung to return to 
its normal state. Otherwise emphysema would be more common in 
adult life than it is. Clinically, emphysema combined with various 
forms of pulmonary disturbance, especially bronchitis, is very com- 
mon in infants and children. My experience in this respect confirms 
that of SteflFen and Osier. It seems to be common to certain classes 
of children, especially those of rachitic tendencies. 

Morbid Anatomy. — Steffen has made a very careful study of 
the pathological condition in emphysema of the lungs of infants 
and children. The thorax has not the typical barrel shape seen in 
the adult, and occasionally found in older children. In younger 
children, especially in those with rachitis, the sides of the lower por- 
tion of the thorax are incurved ; the upper part of the thorax in 
front underneath the clavicles may be full and prominent. On open- 
ing the chest, the lungs are found to be inflated, to retain their form, 
and to show along the situation of the ribs a series of indentations 
due to pressure. The depressed portions may be denser than those 
raised, and show areas of circumscribed persistent pneumonia. In 
vesicular emphysema, air-vesicles may rupture into one another, 
giving rise to large sac-like formations which communicate with a 
bronchus. Some of the air-vesicles may rupture into the subpleural 
tissue. Vesicular emphysema rarely involves a whole lung or 
both lungs, but is localized to certain areas, such as the apices, 
anterior borders, or the lingula. The emphysematous areas are 
whitish, yellowish white, or reddish yellow, the color varying with 
the amount of blood contained. They are raised above the surface, 
are elastic and velvety to the touch, and crepitate with the air con- 
tained. In children, in contrast to the condition in the adult, the 



552 DISEASES OF THE RESPIRATORY SYSTEM. 

heart is rarely dilated, and the liver and kidneys rarely affected. 
This is due to the temporary nature of the process. Bronchitis, 
trachitis, and laryngitis may exist as primary or secondary condi- 
tions. It is not possible to consider emphysema in infants and chil- 
dren as an isolated condition. Since it is most frequently seen in 
pronounced bronchial affections, it will be convenient to consider it 
in connection with bronchitis. 

Symptoms. — Some infants and children suffer from a chronic 
catarrhal bronchitis which is more or less present at all times, and 
which may be interrupted by attacks of acute bronchitis. Infants 
and children thus affected are more or less rachitic ; some have 
lymphatism in the form of chronic hypertrophic rhinitis and also 
adenoids or enlarged tonsils. In the intervals between the attacks 
of acute bronchitis, the patients do not seem to suffer much con- 
stitutional disturbance. There is no fever, and no change in the 
respiration except that it assumes a noisy character. There is a 
cough which comes on at intervals, especially at night. The infants 
are pale, with rather flabby muscles, and may be fat, but impress the 
physician as being below the normal in point of strength. 

Physical Signs. — If the bronchitis has persisted a long time, 
the upper part of the chest is, even in infants under the age of twelve 
months, abnormally full. The upper costosternal region is high 
and the intercostal spaces are filled out. In milder cases there are 
no signs to be detected on inspection. 

Palpation. — There is distinct rhonchal fremitus felt anteriorly and 
posteriorly. 

Percussion. — If there have been a number of acute attacks, there 
will be emphysema of a vesicular type, giving a hyper-resonant 
note. In pronounced rachitis the hyper-resonance is apt to be 
marked. The area of relative cardiac dulness in older children 
is much diminished (Fig. 102). 

Auscultation. — Voice-sounds are normal. The breathing is rude 
or sonorous. The respiratory murmur may be prolonged. There 
are sonorous, mucous, and subcrepitant rales. 

A second set of cases of chronic bronchitis comprises those in 
which a condition of pronounced emphysema of a vesicular charac- 
ter is present, and in which there are distinct attacks of dyspnoea or 
asthma. These cases must be differentiated from the purely neurotic 
cases of spasmodic asthma. The latter condition is rare in chil- 
dren, and is not accompanied by chronic catarrhal bronchitis. The 
history of these cases is one of repeated attacks of acute bronchitis. 
The lung may in the interval be wholly free from signs of bronchitis. 
A condition of this kind is apt to be left in the lung after a severe 
attack of pertussis. The infants or children may bear the marks 
of rachitis, and are usually anaemic. In the intervals between the 
acute attacks of asthma, the general condition is good. There is no 



EMPHYSEMA AND CHRONIC BRONCHITIS OF THE LUNGS. 553 

fever ; there may be dyspnoea on exertion. An attack of asthma is 
precipitated by exposure to cold or wet. During the attacks infants 
and children do not suffer much, although they show signs of 
marked dyspnoea. There are none of the typical signs of an attack 
of spasmodic asthma in the adult. An infant showing very 
marked dyspnoea will play in the arms of the mother. The lips 
may be cyanosed and the surface pale and cool. There is no tem- 
perature. There is in these subjects a tendency to develop a cough 
of a laryngeal type on the least exposure. Examination of the 



Fig. 102. 




Emphysema of the lung in a boy eight years of age ; diminished cardiac area of relativ; 

dulness. 

chest shows nothing except a prolonged rude respiratory murmur, 
while percussion will give a hyper-resonant note over the whole 
chest. Suddenly an attack of so-called asthma will develop, with 
all the physical signs given below. The onset of the attack is 
sometimes signalized by a slight rise of temperature, 100° to 101° 
F. (37.7° to 38.3° C), and an increase in the number of respira- 
tions, 32 to 36 per minute. On examination, the chest shows all the 
signs of an acute attack of bronchitic asthma. An attack lasts for 
from a few hours to a few days. The children usually play about 
and seem little disturbed by their condition. 



554 



DISEASES OF THE RESPIRATORY SYSTEM. 



Physical Signs. — During an attack of spasmodic dyspnoea: 
Inspection shows a drawing inward of the supersternal structures 
on inspiration, and a depression of the peripneumouic groove. 
The upper part of the chest is high and filled out, and moves little 
on inspiration and expiration. The lower part of the thorax has 
also little movement. In rachitic children, there is not only drawing 
inward of the lower part of the thorax, but also a distinct incurvation 
of the lower ribs, caused by the repeated attacks of dyspnoea. The 
chest is moved as a whole. In children of seven or eight years the 
dyspnoea may be severe in the absence of cyanosis. These patients 
apparently suffer more than infants. 

Fig. 103. 




Emphysema of lung : boy eight years of age ; barrel-shaped thorax. Same patient as Fig. 102. 

In older children, the chest has the typical barrel shape seen in 
the adult sufferer from asthma (Fig. 103). In one case, my notes 
describe a drawing inward of the intercostal spaces. Some cases 
have a constant cough and frothy expectoration. 

Palpation gives rhonchal fremitus and faint cardiac impulse. 

Percussion gives a vesiculotympanitic or hyper-resonant note over 
the whole chest, and cardiac dulness obscured and diminished by 
the emphysematous lung. 

Auscultation gives a prolonged expiratory murmur and sibilant 
and sonorous rales. Heart-sounds are feeble. 

Between the attacks of dyspnoea the chest retains the above forms. 
There may be a slight constant dyspnoea or none at all. The patient 



EMPHYSEMA AND CHRONIC BRONCHITIS OF THE LUNGS 555 

feels quite well, and does not complain of the dyspnoea. The heart 
apex-impulse is diffused. 

Palpation gives little or no rhonchal fremitus. Percussion shows 
a note hyper-resonant, but not as markedly so as during the par- 
oxysm of dyspnoea. Cardiac relative dulness is obscured by the 
presence of emphysema. 

Auscultation. — In older children the expiratory murmur may 
be prolonged or inaudible. There are signs of residual bronchitis, 
sibilant, sonorous, and subcrepitant rales, and in young infants, large 
mucous rales. The signs may be hardly noticeable or heard only in 
certain portions of the chest. 

Prognosis. — In both forms of chronic bronchitis the prognosis 
quoad vitam is very good. The chances of ultimate restoration of 
the luDg to the normal condition depend much on the mode of 
living and the power of the individual to outgrow the conditions of 
rachitis and lymphatism which exist in many of these cases. Many 
of these forms of chronic bronchitis disappear ultimately ; the emphy- 
sematous form may persist into adult life. 

The treatment of chronic bronchitis is directed toward improv- 
ing the general tone of the economy and also the musculature of the 
heart. It must be assumed that in these cases the heart as well as the 
other organs suffers from a lack of power, to which may be attrib- 
uted the relaxed condition of the circulation in the mucous mem- 
brane of the bronchi. Life in the open air, hydriatic treatment, and 
heart tonics, such as strychnine, will have beneficial effects. The 
mucous membranes are benefited by preparations of iron which con- 
tain iodine (syrup of the iodide of iron), freshly prepared and given 
in large doses. Cod-liver oil is an excellent tonic in winter. The skin 
should be protected from extremes of heat and cold by suitable under- 
wear. Moderate participation in sports in the open air improves the 
action of the heart. Punning and gymnastics are to be preferred to 
bicycle-riding. 

A dry climate will do much toward improving the condition of 
the lung. During the attack of dyspnoea, iodide of potassium will 
be of service in alleviating the symptoms. This is the most useful 
remedy. It is also of great benefit when given in the intervals between 
the attacks. The other drugs used with adults are not indicated. 
An exception is Fowler's solution, which is an exceedingly useful 
remedy in moderate dosage in the intervals of the attacks, to be given, 
over a prolonged period. I have seen good results follow the use 
of digitalis in the form of the tincture, in combination with the iodide 
of potassium. The heart is thus greatly aided in improving the cir- 
culatory conditions in the emphysematous lung. Rest from exertion 
is indicated during the attack, but patients may be kept out of doors 
if they will remain quiet. Codeine is most useful in allaying the 
cough. The administration of a large dose once or twice daily is 
preferable to giving small doses at shorter intervals. 



556 DISEASES OF THE RESPIRATORY SYSTEM. 

Bronchiectasis. 
Including Putrid Bronchitis. 

Bronchiectasis, or dilatation of the bronchi, is not a very uncom- 
mon condition in infants and children. In most pulmonary dis- 
orders in these subjects, very slight dilatations of the bronchi may 
result. These have no clinical significance, and retrograde to the 
normal state in time. The marked dilatations are the congenital 
bronchiectasis and the acquired or inflammatory form. 

Congenital Bronchiectasis. — This is a condition of the newly born 
infant which has been known to persist into adult life (Grawitz, 
Welch, Kessler, Frankel). It generally affects one lung or a part 
of one lung. The lung structure is replaced by cystic formations 
which contain a serous fluid, in which are found nuclei and ciliated 
epithelium. The main bronchi may be cystic, with a system of 
minor cavities separated from the main cavity by a series of septa. 
In this way numerous recesses are formed. The walls of the cysts 
may be covered with several layers of cuboidal epithelium. No 
distinctive symptomatology has been reported in these cases. 

Morbid Anatomy. — Inflammatory Form. — The inflammatory 
form of bronchiectasis may be sacculated, spindle-shaped, or cylin- 
drical (vicarious). The cylindrical bronchiectasis shows the bronchus 
dilated into a cylindrical form. This dilatation may merge gradually 
or abruptly into the main bronchus. The spindle-shaped bronchiec- 
tasis is only a form of the cylindrical variety. 

The sacculated bronchiectasis is the most common variety, and 
clinically the most important. It usually affects the smaller bronchi. 
A sac communicates with the trachea, and has no other outlet. 
The entry into the sac may be by way of a normal, a dilated, or a 
stenosed bronchus. If the infundibula are dilated, small cavities 
are formed (pulmonary vacuoles). In other cases the afferent 
bronchus may be obliterated, and the cystic formations are then 
of varying size. The wall of the bronchus leading to a cavity of 
this nature is in a state of catarrh, and may be thickened or infil- 
trated. The epithelium may be present only in spots. The infil- 
tration may affect the walls of the alveolar septa. The mucous mem- 
brane may after a time become atrophic. The cartilages of the 
bronchi may also become atrophic and be replaced by connective 
tissue which may extend for varying distances into the lung sub- 
stance, forming trabecule. The epithelium of the bronchi may be 
replaced by pavement epithelium. The mucous membrane becomes 
thickened or is replaced by polypoid masses. The bloodvessels finally 
become dilated. There may thus be formed throughout the lung 
small aneurismal dilatations of the bloodvessels. The remaining lung 



BRONCHIECTASIS. 557 

tissue may be emphysematous or sclerosed as above. The pleura 
may be thickened. 

Etiology. — Whatever the exact cause of a bronchiectasis, there 
is certainly a diminished resistance of the walls of the bronchus to the 
inroads of inflammatory processes. In order to explain the immediate 
formation of these cavities, Hoffman has assumed that a stenosis of 
the lumen of the bronchus (as shown by Frankel and Lichtheim), 
must be produced by inflammatory processes and that under these 
conditions the repeated attacks of coughing produce dilatation. 
Such stenosis may have its origin in a peribronchitis or a pneu- 
monia causing thickening of the wall of the bronchus. Pleurisy, 
chronic pneumonia, croupous or catarrhal, syphilis, and foreign bodies 
lodged in the lumen of the bronchi may be the direct cause of a 
bronchiectasis. Finally, there are the forms of bronchiectasis called 
primary, because their etiology has not as yet been explained. 

Symptomatology. — The symptoms include expectoration, a 
cough, dyspnoea, deformity of the chest, and fever. 

Expectoration. — There is expectoration of a mucopurulent char- 
acter, which cannot be differentiated from the expectoration of 
some forms of bronchitis. In other cases, large quantities of a fetid, 
purulent material are expectorated. This expectoration may at 
times be mingled with streaks of blood, or there may be a distinct 
hemorrhage. In some cases there is a fatal haemoptysis. Some- 
times the sputum is profuse, exceedingly fetid, fluid, and purulent, 
and will on standing separate into a serous and a purulent portion. 

The cough may be occasional or, if the bronchiectasis exists in 
the apex of the lung, incessant. It is apt to be more marked in the 
morning, and may at that time be accompanied by the expectoration 
of the sputum accumulated during the night. At other times, change 
of position will cause paroxysms of coughing and the evacuation of 
large quantities of sputum. 

Dyspnoea is present not only during the paroxysms of coughing, 
but also in the intervals, especially if there are extensive secondary 
changes in the lungs or pleura. 

Fever of a hectic character is very likely to be present at times 
when the secretion in the lung accumulates. The temperature will 
then show a rise of a degree or more, but subsides when the lung is 
again cleared of bronchiectatic accumulations (Fig. 104). The rises 
of temperature may simulate those in empyema or tuberculosis. If 
abscess of the liver or kidney, endocarditis, or pneumonia occurs as 
a complication, the rise of temperature will be more marked. 

Deformity of the chest is apt to occur in severe cases in which 
there is emphysema of the lung or pleuritis. In 3 of my cases 
there have been deformities of the fingers and toes. These, the 
so-called clubbed fingers, are not characteristic of bronchiectasis, 
since thev are found in congenital cardiac disease and tuberculosis 



558 



DISEASES OF THE RESPIRATORY SYSTE3L 



of the lung. There is pain as a result of existent pleurisy. Albu- 
minuria may be present as a result of amyloid changes. Hsemop- 
tyosis is generally a late symptom, but is not very common. Diar- 
rhoea of a septie nature may occur in the course of the disease. 

Complications include decomposition of the bronchiectatic accu- 
mulations, pneumonia, gangrene of the lung, emphysema, pleurisy, 
empyema, perforation of the lung, laryngeal disease, kidney and 
heart disease, liver abscess, abscess of the brain, and finally amyloid 
degeneration of the liver, spleen, and kidneys. 

Diagnosis. — A positive diagnosis of bronchiectasis cannot always 
be made, especially in those cases in which there are all the signs of 

Fig. 104. 



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WEIGHT 3. LBS. 32 LBS. 



Bronchiectasis : febrile and afebrile periods. Boy, seven years of age. 

a localized empyema. Such cases show localized dulness or flatness, 
bronchophony, and absence of fremitus in a certain portion of the 
chest, generally at the lower portion behind. A needle, on being 
introduced, withdraws pus, which in the cases I have seen was min- 
gled with air bubbles. On operation, the pleura is found to be 
normal. In 3 instances I found this to be true. The evidence 
of a bronchiectatic cavity lay in the persistence of signs and symp- 
toms after the healing of the chest wounds. In all 3 cases the 
expectoration persisted in profuse quantities after operation (Fig. 

The physical signs in all of my cases included a localized area 
of dulness or flatness, over which there was bronchophony and bron- 
chial breathing, in some cases with gurgles. Above this area, over 
the base behind, there was on percussion a tympanitic note, indi- 
cating the enlarged bronchus containing air. Tuberculosis is 



BRONCHIECTASIS. 559 

excluded by the absence of tubercle bacilli in the sputum, but bron- 
chiectasis and tuberculosis may coexist. In most of my cases there 
was a history of an antecedent attack of pneumonia. Exclusion of 
abscess of the lung is very difficult in severe cases in which the 
quantity of sputum is excessive. The bronchiectatic cavity in these 
cases is very large. With the bronchiectasis, there may be diffuse 
bronchitis and emphysema of the lung. 

P^G. 105. 




I 

Showing bronchiectatio cavity in case of a girl eight years of page, with signs as noted in 

text. 

Course. — Some of the cases in which the bronchiectasis is not 
marked or progressive result in spontaneous recovery. In others 
there may be tuberculosis, gangrene of the lung, or empyema, as 
complications. A fatal haemoptysis may close the scene of this very 
offensive affection. 

Treatment does not give very satisfactory results. It includes 
the inhalation of balsams of all kinds, out-of-door life in high alti- 
tudes, and surgical interference including exposure of the lung and 
incision of the bronchiectatic cavity. The latter is a desperate 
remedy ; in some cases it has resulted in fatal hemorrhage and in 
others has not afforded relief. A cure has resulted in a few rare 
cases in which there was a simple cavity in the lung near the 
pleural surface. The injection of these cavities with drugs has also 
been very unsatisfactory. 



660 DISEASES OF THE RESPIRATORY SYSTEM. 



V. DISEASES OF THE LUNGS. 

General Considerations. — The lungs at birth are small as com- 
pared to the other organs in the chest. They grow comparatively 
more in the first few months of infancy ; bat in children they remain 
small as compared to tlie body-weight and length. Compared to the 
heart in volume during the first months of infancy, the lungs are as 
3.5 or 4 to 1. In the later months of infancy the lungs develop 
more rapidly, and then the ratio of volume of the lungs to the heart 
is as 5.5 or 6.2 to 1. 

Nose-breathing is the normal mode of breathing in infants. 
If an infant is studied as it sleeps, though the lips be parted and the 
mouth open, it will be seen that the tongue is apposed to the roof of 
the mouth, and that the breathing is purely nasal. If there is any 
obstruction in the nasal passages due to swelling of the mucous mem- 
brane, or an accumulation of nasal secretion, the infant will not only 
have noisy breathing, but there will be a suction backward of the 
tip of the tongue, and we will observe the so-called swallowing of 
the tongue. As soon as the nasal passages are cleared of mucus, or 
the swelling of the mucous membrane subsides, the infant will breathe 
quietly. In the young infant mouth-breathing is rarely seen. The 
infant has not learned as yet to overcome the obstacles to nasal 
breathing, should these exist, by breathing through the mouth. Later 
on in childhood mouth-breathing appears. Therefore adenoid vege- 
tations in young infants may lead to greater difficulties in breathing 
than in older infants or children. 

Movements of the Chest. — The movements of the chest may 
normally be irregular in rhythm ; the sides move symmetrically. 

In disease, especially in conditions of pressure on one side of the 
neck, one side of the chest may remain immobile, the other being 
retracted with each respiration to an exaggerated degree. I have 
observed this condition after operations for retropharyngeal abscess 
in the neck, in cases in which the nerves in this region were pressed 
upon or injured, thus interfering with the normal action of the dia- 
phragm. 

In effusion into one side of the chest, there is diminished motion 
on the diseased side. Emphysema may restrict the normal move- 
ments. 

Cheyne-Stokes respiration is seen in cerebral disease. After a 
deep and full inspiration the respirations become increasingly shallow 
until they are scarcely perceptible. A deep inspiration is then taken, 
and the respirations become more and more marked in the ascending 
scale, finally reaching the original force and depth. The cycle is 
then repeated. 



DISEASES OF THE LUNGS, 561 

In forms of pleurisy with effusion the intercostal spaces are re- 
tracted more than is normal at each descent of the diaphragm. This 
may be due to adhesions. The prsecordial region may be drawn in- 
ward with the recoil of the heart, as is sometimes seen in adherent 
pericardium. 

SkoUosis of the spine may deform the chest, giving undue promi- 
nence to one side. Retraction occurs after the absorption of pleuritic 
effusions. 

Fremitus. — The method of obtaining fremitus in children is 
described on page 40. It may be mentioned here that fremitus is 
well marked normally in the posterior axillary line and in the inter- 
scapular region. 

The Normal Limits of the Lungs. — In the mammillary line on 
the right side to the sixth rib ; in the mid-axillary line to the ninth 
rib. Posteriorly on the right side to the tenth rib ; on the left side 
to the eleventh rib. Thus the limits are practically the same as in 
the adult subject (Symington). 

The amount of lung-tissue above the clavicle cannot be mapped 
out in infants and children. 

Resiliency of the Chest-wall. — The chest-Avall in infants and 
children has a normal resiliency to percussion. The wall gives 
beneath the finger. This is a definite feature. In any disease of 
the chest which interposes fluid between the chest-wall and the lung 
this resiliency of the wall is absent. In infants and children, as in 
adults, there are normally : 
Pulmonary resonance ; 
Dulness varying to flatness ; 
Tympanitic resonance. 

Pulmonary resonance is lower in pitch than in the adult. Ante- 
riorly over the right infraclavicular region it is less marked than on 
the left side ; the note is also slightly higher and of shorter duration. 

Dulness is found normally over the heart, liver, and spleen ; also, 
anteriorly on the right side from the fourth to the sixth rib. From 
the sixth rib to the borders of the ribs the note is flat. In the mid- 
axillary line on the right side there is dulness from the fifth to the 
seventh rib ; from this point to the free border, the note is quite flat. 
On the left side at the level of the sixth rib, just above the spleen, 
there is a narrow strip of relative dulness, due to the presence be- 
neath the diaphragm of the left lobe of the liver (Fleischman) 
(Fig. 106). 

Posteriorly the supraspinous regions give dulness, but not so 
markedly as in the adult. On the right side, from the level of the 
seventh dorsal vertebra, extending downward, there is dulness due 
to the liver. 

Tympanitic resonance due to the stomach is found normally in 



662 



DISEASES OF THE RESPIRATORY SYSTEM. 



the left axillary line. It may in some cases extend high up in the 
axilla. 

Auscultation. — As a rule, there is little difficulty in obtaining 
the respiratory murmur and voice-sounds in infants and children — 
certainly not in the latter. The crying of unruly infants is useful 

Fig. 106. 




Strip of relative dulness described by Fleischman.and found just above the spleen, supposed 
to be due to the presence of the left lobe of the liver. Child, two years of age. 



in that it gives the fremitus and the quality of the voice-sounds. In 
some cases the infants are very quiet during examination, and un- 
less they are teased into crying, definite information on these points 
cannot be obtained. The infant is caused to cry by gently squeezing 
the cheeks with the thumb and index finger. 

The Breathing. — The respiratory sounds in infants and children 



DISEASES OF THE LUNGS. 563 

are of an intensified vesicular quality ; this so-called puerile breath- 
ing is normal and constant in children under twelve years of age. 
The quality of the vesicular murmur is probably caused by the 
better conducting qualities of the chest at this age. The elasticity 
of the lungs, which causes greater resistance to the inspiratory dilata- 
tion, is also a factor in producing the puerile quality of the respira- 
tory sounds (Gutman). 

Types of Puerile Breathing. — Puerile breathing in infants and 
children may be classified as follows : 

a. The most common type is that in which the inspiration is 
coarse or intense in quality, while the expiration is vesicular and 
almost inaudible. 

b. The second type of puerile breathing is that in which the in- 
spiration and expiration are both of an intensified coarse quality. 

c. The third type is that in which the inspiratory sound is low 
and vesicular, and the expiratory, coarse and puerile. 

These types are found in infants and children at rest. If they 
are caused to cry, both the inspiratory and the expiratory murmur 
are of a coarse puerile quality. In some infants and children at 
rest, the inspiration and expiration are vesicular as in the adult. 
Puerile breathing is frequently confounded with bronchial breathing. 
It is, however, never tubular in quality. Bronchial or tubular 
breathing is marked on expiration ; puerile breathing is generally so 
on inspiration. 

During auscultation the sides of the chest are always compared. 
On the right side, beneath the clavicle and over the spine of the 
scapula, the expiratory murmur is more intense than on the left side. 
This should be especially remembered in cases in which disease 
of the right apex is suspected. The quality of the breathing in 
these regions approaches the bronchovesicular. 

Posteriorly, the respiratory murmur may be heard as far down as 
the level of the eleventh dorsal vertebra. In some children the 
sounds are not so intense toward the base of the lung behind as 
higher up in the chest. 

Bronchovesicular breathing is heard normally in the interscapu- 
lar region in children as in adults. It has the same qualities as in 
the adult. 

Bronchial breathing is heard normally over the trachea and upper 
part of the sternum. It is also called tubular, tracheal, and over 
the larynx, laryngeal breathing. 

Forms of Dyspnoea. — Though mainly of two types, pulmonary 
and laryngeal, dyspnoea may be caused by pain, fever, cardiac dis- 
ease, and abdominal tumors. 

Pulmonary Dyspnoea. — There is not only an increase in the num- 
ber of respiratory movements, but also a change in the depth of 
each respiratory eifort. In the dyspnoea of pulmonary disease, the 



564 DISEASES OF THE RESPIRATORY SYSTEM. 

region at the border of the ribs adjacent to the abdominal walls 
(peripneumonic groove) is drawn forcibly inward at each inspiration. 
In emphysema with asthmatic attacks, it will be noticed that during 
the attack the upper part of the thorax is immobile, the inferior part 
being drawn inward with each inspiratory effort. The presence of 
fluid in one side of the chest may be suspected if the side remains 
immobile, or if the intercostal spaces are drawn inward with each 
forced inspiration. A splenic or nephritic tumor may also, by simple 
upward pressure, immobilize one side of the chest. 

Laryngeal dyspnoea will occur in any obstructive disease of the 
larynx. In addition to the phenomena of the pulmonary form of 
dyspnoea, there is a distinct retraction of the tissues at the situation 
of the suprasternal notch. There may also be laryngeal or croupy 
breathing. 

While this is true in the majority of cases, I have also seen 
the retraction of the suprasternal notch, described above, pres- 
ent in the later stages of severe forms of acute pulmonary disease, 
especially in children ; also in cases of emphysema in the asthmatic 
attack. 

Pain will cause an increase in the number of respiratory move- 
ments. Thus the pain of an incipient pleurisy will cause an increased 
number of respirations which are more shallow than is normal. 
Peritonitic pain will also cause the respirations to become shallower 
and to increase in number. 

Fever will, especially in infants and children, increase the number 
of respiratory movements to 40 or more, without the presence of any 
lung disease. 

Cardiac dyspnoea is seen in those diseases of the heart which 
cause a retardation of the pulmonic circulation. The aeration of 
the blood in the capillaries of the lung is considerably iuterfered 
with under these conditions. Mitral disease, stenosis, and regurgi- 
tation cause dyspnoea not only for the reason given above, but also, 
in the later stages, on account of the bronchitis which is the result 
of the cardiac disease. Anaemia of cardiac disease is also accom- 
panied by a slight dyspnoea, which is especially marked in children. 
The slightest exertion will sometimes cause angina and dyspnoea in 
children suifering from a slight cardiac lesion. 

Ascites and abdominal tumors, or enlarged organs, such as the 
liver or spleen, will cause dyspnoea, especially when patients are in 
the recumbent position. 

In weak infants a few days old, who are the subjects of atelectasis 
and pneumonia, the upper part of the chest-wall moves very little, 
while the inferior portion of the chest and the upper part of the abdo- 
men (peripneumonic groove) are drawn inward at each inspiration. 



LOBAR PNEUMONIA. 565 

Pneumonia. 
Lobar Pneumonia. 

{FibrinoiLS Pneumonia, Croupous Pneumonia or Pneumonic Fever). 

Lobar pneumonia or fibrinous pneumonia is an acute infectious 
disease, caused in the majority of cases by the Diplococcus pneu- 
moniae (FrankelV A few cases are caused by the Bacillus pneu- 
moniae (iFriedlander) ; others, by the Streptococcus or Staphylococcus 
pyogenes. 

Occurrence. — Lobar pneumonia occurs as a primary disease 
or may complicate typhus fever, typhoid fever, influenza, rheuma- 
tism, malarial fever, erysipelas, osteomyelitis, meningitis, and neph- 
ritis. According to Keller, from 58 to 62 per cent, of all lobar 
pneumonias occur among children, the frequency among boys being 
greater (55.9 per cent.). Fully two-thirds of the cases occur during 
the winter and early spring. Pneumonia of any variety, and espe- 
cially of this form, may occur in groups of persons or in small local 
epidemics. Without doubt, certain houses and rooms harbor the 
pneumonia poison for some time, as is evinced by the repeated 
occurrence of cases in certain places (Jiirgensen). Cold favors the 
development of pneumonia by reducing the resistance of the economy 
to the invasion of bacteria, but it cannot be regarded as a cause of 
the disease. 

Age. — Lobar pneumonia may occur at any age of infancy or 
childhood. Von Jaksch has shown that it occurs among young 
infants. My own experience confirms this statement. Out of 839 
of my cases of pneumonia of all types, 582, or 69 per cent., occurred 
before the end of the second year ; the greatest frequency was 
between the first and second years (282 cases). From birth to the 
sixth month the frequency is less than from the sixth month to the 
end of the second year. 

Sex. — The male sex shows the greater number of cases (436 
males, 403 females). Of 147 cases of carefully observed lobar 
pneumonia, 89 were males and 58 females. 

Seat of the Disease. — Jiirgensen shows that in 162 cases, both 
lungs were affected in 7.4 per cent. The right lung only was 
affected in 43.2 per cent, of the cases. When the right lung was 
attacked, the lower lobe was generally the seat of the disease (25.3 
per cent.). The lower lobe of the left lung was consolidated in 35 
per cent, of the cases. 

Of 217 of my cases of lobar pneumonia, the right lung was 
involved in 124 cases and the left in 93 ; the upper right lobe was 
involved in 74 cases ; the upper left, in 35. The upper lobe of 
either lung was involved in 109 cases, as against 100 cases of the 
lower lobes. The middle right lobe was involved in only 8 cases. 

Upper lobe. Middle lobe. Lower lobe. 

Right lung 74 8 42 

Left " 35 . . 58 



666 DISEASES OF THE RESPIRATORY SYSTEM. 

Pneumonia of the upper lobe is more frequent in children than 
in adults. According to Jiirgensen, the greater frequency of pneu- 
monia in the right lung may be attributed to the larger size of the 
right bronchus and the more direct communication with the lung. 

Morbid Anatomy. — Lobar pneumonia in infancy and child- 
hood is^ as in adult life, distinguished by the occurrence of a 
fibrinous exudate in the alveoli of the lungs, bronchioles, and lymph- 
spaces. This exudate is composed of desquamated epithelium, leu- 
cocytes, red -blood cells, and fibrin. The proportion of leucocytes, 
red blood-cells, and fibrin varies greatly at different stages of the 
affection. A fluid exudate may be present if the quantity of fibrin 
is small. In such cases there is a lobar catarrhal process or an 
inflammatory (edema of the lung. The exudate begins with con- 
gestive hypersemia. The lung is dark red and of increased con- 
sistency. With the appearance of coagulation there is produced a 
condition of hepatization in which the lung is solid, and has the 
appearance of liver. The bloodvessels are filled with red cells. If 
the vessels are less engorged, the lung has a grayish tint. This 
later stage, called gray hepatization, is the condition most frequently 
seen at autopsy. The hepatized lung does not contain any air, and 
on section shows a granular surface, the granules being the so-called 
pneumonic granules of the later stage of the disease. The pleura 
is as a rule inflamed. It is without lustre and may be thickened 
and covered with fibrin. There may be considerable serous or sero- 
purulent exudate in the pleural cavity. The extent of hepatization 
varies. It may involve a whole lobe, part of the lobe of a lung, or 
parts of both lungs. On inspection of the surface of a section, 
small yellow areas may be seen in the hepatized portions. These 
are areas poor in fibrin, and correspond to the situation of the 
bronchioles of the lung. 

The bronchial nodes may be red and swollen, the bronchi being 
the seat of inflammation. The bronchioles may be filled with fibrin 
and red blood-cells. 

Resolution occurs on from the seventh to the tenth day of the 
disease. At this time liquefaction of the inflammatory products 
which are eliminated by expectoration occurs. Complete restoration 
of the lung to the normal may occur between the second and the 
fourth week, at which time the periphery of the alveoli may be found 
to be rich in cells. There may still exist catarrhal processes which 
have succeeded the fibrinous changes. The pleura may remain 
thickened and be the seat of adhesions. 

An unfavorable or malignant ending, such as gangrene or sup- 
puration, is rare, and is as a rule due to some mixed infection favored 
by an old bronchiectasis or putrid bronchitis. Unless a tuberculous 
infection occurs, caseation in lobar pneumonia is unknown. Indu- 
ration of the lung, cirrhosis or carnification, is a peculiar condition 



LOBAR PNEUMONIA. 567 

which may occur from the fourth to the tenth week. The hmg 
assumes a beefy red appearance and is tough, hypersemic, and 
infiltrated with small round cells. The alveoli enclose a large 
number of connective-tissue cells. There is a proliferation of newly 
formed bloodvessels in the septa of the lung. The bronchial, peri- 
bronchial, and pleural tissues are proliferated. Induration of the 
lung by pleural adhesions results. The alveoli of the lung may 
be replaced by connective tissue and epithelium. Induration may 
take the form of bands of connective tissue, which may extend from 
the pleura into the lung, enclosing areas of lung-tissue. 

Bacteriology and Etiology. — The pneumococcus of Frankel is 
now recognized as the etiological factor in lobar pneumonia. As 
has been mentioned, the Bacillus pneumoniae of Friedlander is 
found in a small number of cases, with the pneumococcus or 
with other bacteria. The Streptococci pyogenes and the Staphy- 
lococcus pyogenes are sometimes found, as well as the Bacillus 
typhosus. In the cases of secondary infection, the Diplococcus pneu- 
moniae or the Staphylococcus pyogenes is found. In the majority 
of fatal cases, Kohn found the pneumococcus circulating in the 
blood. The cases which show the diplococcus in the blood and 
which recover, do so with complications. In a recurrent pneu- 
monia of infancy, Perutz found an osteomyelitis of the joint, caused 
by pneumococci. In one of my cases which was followed by bilateral 
empyema, there was a peri-articular abscess containing pneumococci. 
According to Landouzy and Netter, the pneumococcus is capable 
of producing suppuration without the intervention of streptococci 
or staphylococci. Cases of severe icterus are due to the hsemolytic 
action of the pneumococci on the blood. Gaillard has shown that 
the enteritis in pneumonia is caused by pneumococci. 

Symptomatology. — There are forms of fibrinous or lobar 
pneumonia which present the same symptomatology in children as 
in the adult. On the other hand, certain sets of symptoms referable 
to the nervous system and intestinal tract, as well as the character 
of the variations in temperature, are peculiar to infancy and 
childhood. 

The disease may be ushered in by a chill, which may be severe 
or only amount to a sensation of chilliness. Susceptible subjects 
may, with the rise of temperature, be attacked with convulsions. 
Other patients pass into a stage of delirium lasting for days. 
Cases of pneumonia ushered in with cerebral symptoms are apt to 
mislead the physician, especially if meningitis has been recently 
prevalent. There are also cases, especially in children, in which 
there has been a preceding bronchitis. These should not be regarded 
as being of necessity cases of bronchopneumonia. Sometimes the chill 
is coincident with a sharp attack of enteritis. The character of the 
invasion will thus vary with the severity of the infection and the 



568 



DISEASES OF THE RESPIBATOBY SYSTEM. 



susceptibility of the subject. After the initial chill, there is in the 
simple cases a sharp rise of temperature. The height of the fever 
varies, and in young infants is apt to mount to 106° F. (41.1° C). 
There are cough and considerable dyspnoea, varying with the extent 
of lung involvement. In infants and children the dyspnoea is quite 
apparent to the eye of the observer^ and will prompt him to surmise 
that the lung may be involved. Older children have a distressed 
expression. In cases in which sopor is present, the dyspnoea is apt 
to be more evident than in those cases in which this cerebral symptom 
is absent. This apparent dyspnoea is only relative. A conscious 
patient does not show this dyspnoea as much as one who is uncon- 
scious. 

Fig. 107. 



DAY OF 

MONTH 


Oct. 21 


22 


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.. 1 


HOUR 


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Lobar pneumonia; pseudocrisis and crisis. Leucocyte count before and after crisis indi- 
cated. Boy four years of age. 

The patient complains of pain, which is in many cases referred 
to the side affected. In younger children the pain is quite fre- 
quently referred to the epigastrium, but sometimes to the region of 
the abdomen low down, or to the right side of the abdomen low 
down over the situation of the vermiform appendix. Pain is apt 
to be referred to this region in cases of lobar consolidation of the 
lower portion of the right lung. These are often, in the early 
stages, diagnosed as cases of appendicitis. The face is pale or 



LOBAR PNEUMONIA. 



569 



quite flushed. The dyspoena may be slight, but is quite marked 
in some severe cases. Even if both lungs are involved, it may 
not be intense. There is a cough. In older children there is 
expectoration of rusty sputa. Infants and young children swal- 
low the sputum. Infants cry with each paroxysm of coughing; 
older children complain of pain. Sometimes infants and children 
vomit v/ith each attack of coughing. After the fever has persisted 
with these symptoms for from five to nine days, there occurs in 
the vast majority of cases a fall of the temperature — the so-called 
crisis — which may take place within from three to six hours, or 
may extend over thirty-six hours. The fall of temperature may 
be followed by a temporary rise of a few degrees (Fig. 107) — the 
so-called pseudocrisis ; within a few hours it then falls to the 
subnormal, where it remains for a few days after the crisiSj finally 



Fig. 108. 


HOUR 369 12 369 12 36a |l2 369 12 369 12 o69 12 309 12 3ti9 12 369 12 369 12 369 12 36a 12 369 12 369 12 

\ ~%ii ^ - - = = 


"^° = = = = -fc-=:^i| === = = = ^ 


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LEUCO- § 1 1 
CYTES S S S 



Lobar pneumonia, right lung, lower lobe. Crisis on the eighth day. Leucocyte count 
indicated. Female child, two years and five months of age. 



rising to the normal and remaining at that point throughout con- 
valescence. The temperature may fall by lysis, that is to say, by 
reaching with gradual remissions the normal, or as a rule the sub- 
normal, within from forty-eight to seventy-two hours. 

Consideration of Individual Symptoms. — The Temperature. — 
The temperature-curve in lobar or fibrinous pneumonia may be of 
several distinct types. In the majority of cases the temperature 
remains persistently high for the whole period of the illness. There 
are morning remissions of a degree or more, but the afternoon or 
evening rise may reach 104^ 105°, 106° F. (40°, 40.e5°, 41.1° C). 
In a typical case the morning remissions are not so great as those in 
pneumonia of the bronchopneumonic type. The crisis is not as a 
rule preceded by a rise. The drop of the temperature at the crisis 
in a fairly typical case may begin at 9 a.m., and the temperature 



570 



DISEASES OF THE RESPIRATORY SYSTEM. 



may be subnormal at 9 p.m. of the same day (Fig. 108). In another 
form, crisis may be rapidly followed by a temporary rise in the 
temperature, not due to any reinfection of the lung, but to a slight 
post-pneumonic toxaemia. The temperature will in such cases reach 
the subnormal within thirty-six hours. 

Another very distinct form of temperature-curve is the remittent. 
This temperature-curve is at first glance exactly similar to that of 



Fig. 109. 



HOUR 3 6 9 12 3 6 9 12 3 6 9 12 3 6 9 12 3 6 9 12 3 6 9 12 3 6 9 12 


3 6 9 12 3 6 9 12 3 8 9 12 3 8 9 12 3 6 9 12 3 6 9 12 3 6 9 12 


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URINE XXX XXXXXXX XXX XXXX X XX 


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28,500 

W.B.C. 

17,000 



Lobar pneumonia, right lung, lower lobe; temperature falls by lysis. Lencocytosis indi- 
cated in the chart. Female child, four years of age. 

bronchopneumonia. The remissions in the morning may reach the 
normal within a fraction of a degree. Such cases may also show at 
the terminal end of the curve a critical drop to the normal. In 
other cases the fall of temperature at the beginning of convalescence 
takes place by what is known as lysis (Fig. 109). In other words, 
the temperature reaches the normal or subnormal by remissions of ' 
temperature in a gradually descending scale extending over two or 
more days. Some cases show a remission of the temperature which 
begins at the ninth day of the disease, and is not completed until the 
fifteenth day. This is occasionally seen in cases in which there are 
apparently no complications. The more common type is that in 
which the lysis begins on the sev^enth or eighth day, and is completed 
in two or three days. Of 57 cases of lobar pneumonia in which a 
reliable history could be obtained, the temperature fell by crisis in 36 



LOBAR PNEUMONIA. 



571 



and by lysis in 21 cases. The crisis, as a rule, occurs from the fifth 
to the ninth day of the disease (60 per cent, of my cases). After 
the lysis or crisis there may be a slight daily rise in temperature of 
a degree or even less, probably indicative of a very mild form of 
post-pneumonic pleurisy. The temperature in such cases falls grad- 
ually, and in four or five days reaches the normal (Fig. 110). 

The subnormal temperature after the crisis or lysis is quite a 
common phenomenon. I have learned not to fear this symptom, but 
to regard it as favorable (Fig. 111). A subnormal temperature may 
persist for days, or even a week or longer, and not uncommonly, 
especially in fibrinous pneumonia which has run a sharp or moder- 
ately severe course, is accompanied by irregularity or abnormal 

Fig. 110. 



ILLNESS 


5 


6 


7 


8 


9 


x« 


11 


12 


13 


14 


15 






IS 1 


HOUR 




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Lobar pneumonia, right lun?. middle lobe ; eflTusion into the pleura. Temperature after 
crisis due to pleurisy. Boy, eight years of age. 

slowness of pulse. A slow pulse (bradycardia) which is at the 
same time irregular is apt to be alarming to the physician, but I 
have never seen any ill effects in these cases if they were treated 
in a rational manner. Such conditions of pulse and temperature 
should be regarded as a reaction from the toxemia which has affected 
the heart muscles. 

Chills, or chilly sensations followed by a rise of temperature dur- 
ing the course of the disease, are in most cases accompanied by 
physical signs of an invasion of a new area of lung. This should 
at least be kept in mind, especially if the rise of temperature is 
abrupt. 

At the crisis in lobar pneumonia I have, in exceptional cases, seen the 
temperature drop within an hour from 103° to 94° F. (34.4° to 39.9° C) and 
the pulse to 48 ; within an hour the temperature rose to 96° F. (35.5° C) and 
the pulse to 70. The temperature gradually rose, so that within seven hours 
it was again 99° F. (37.2° C) in the rectum, the pulse 96. The symptoms 
of mild collapse may accompany the pronounced fall. 



572 



DISEASES OF THE RESPIRATORY SYSTEM. 



The Cough. — Some infants and children cough very little ; in 
others the cough is a very harassing symptom. There is no 
sputum even with the older children, or only after the crisis ; pain 
accompanies the cough, and may be suspected if the infant or child 
cries when it coughs. The pain is referred to the side of the chest, 
to the epigastrium, or to the region of the appendix. The pain 
referred to the appendix in cases of lobar pneumonia is probably 
radiated from a diaphragmatic pleurisy. 



































Fig. 


111 












































DAY Of 
DISEASE 


4 


5 


c 


' 


8 


\ 


10 


11 


1 - 1 


„ 


» 1 


15 


16 


„ 1 


HOUR 


s 


12 


6 I 


1 6 


12 


-: 


lt\ 


2 (i 1 


2 (i 1 


2 B 


12 


b 12 


6 12 


6 12 


6 12 


-A 


ti 12 


B 


iH 


11 


2B 12 


6 12 


12 


6 

E 


12 


B 


e 


=j 


= : 


12 


= 


12 


B 


12 


IS 


6 


12 


s 


IE 


105° 


1 




i 




i 




ill 




E: 


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= = 


= = 


EE 




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^l 




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= : 







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EE 


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il02° 
|l01° 
1 100° 


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f 








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Lobar pneumonia, right lung, upper lobe : remittent temperature-curve ; prolonged 
subnormal temperature intermittent in character; recovery. Female child, two years and 
six months of age. 



Dyspncea. — Infants and young children show marked dyspnoea. 
The alae nasi are dilated and the peripneumonic groove is depressed 
with each inspiration. In very severe dyspnoea in young infants, 
there may be a drawing inward at the suprasternal notch. This 
occurs even in the absence of any laryngeal disturbance, and fre- 
quently simulates laryngeal stenosis. 

Nervous Symptoms. — The cerebral symptoms may at the out- 
set simulate those of cerebrospinal meningitis. There are delirium, 
rigidity of the muscles of the neck, and even opisthotonos. There 
may be no true meningitis. Older children may have a low, mut- 
tering delirium during the whole course of the disease. Near the 
crisis and just before the fall of temperature, I have in a few cases 
seen maniacal delirium, in which the patients were very noisy and 
attempted to get out of bed. I have seen cases of melancholia with 
crying spells during convalescence in female children, and also in 
boys. These symptoms all subsided in time and the patients were 
eventually fully restored. 

The Blood. — It has been noted by Tumas and von Jaksch 
that in pneumonia of the fibrinous variety there are a marked leuco- 



LOBAR PNEUMONIA. 573 

cytosis and an increase in the multinuclear leucocytes, which is 
especially marked at or near the crisis. The proportion of leuco- 
cytes to the red blood-cells in the cubic millimetre may reach 
1 : 40 to 1:70. Ehrlich believes this leucocytosis to be a very 
constant occurrence in typical pneumonia. Billings has investigated 
the relationship of the leucocytosis to the prognosis more fully. 
His work will be referred to in the consideration of the prognosis. 
My own experience covers about ninety cases of fibrinous and bron- 
chopneumonia, examined with reference to leucocytosis. Leucocytosis 
is present in both forms of pneumonia in infancy and childhood, but 
is more marked in the fibrinous forms, the number of leucocytes to the 
cubic millimetre being about twice as great as in the catarrhal forms. 
There was marked leucocytosis in the fatal cases of both forms of 
pneumonia. The increase of the leucocytes in the fibrinous forms 
was especially marked at the time of the crisis. In the broncho- 
pneumonic forms the leucocytes were also high at or about the 
time of the drop in temperature. The diminution of the number of 
leucocytes was in both forms marked either just previous to or after 
the fall in the temperature. From the observations of Billings 
and Ewing, it must be concluded that leucocytosis is a favorable 
sign in fibrinous pneumonia. It does not, however, as Ewing 
believed, bear any exact ratio to the extent of lung involved. I 
have found a much higher percentage of leucocytes to the cubic 
millimetre in children than Ewing found in the adult. This is 
probably due to the fact that any leucocytosis is more marked in 
infants and children than in the adult subject. The absence of 
leucocytosis is certainly a grave prognostic sign, but the presence 
of marked leucocytosis in children does not in my experience 
preclude a fatal issue. 

Physical Signs. — The signs obtained by physical examination 
of the chest in fibrinous pneumonia of infants and children resemble 
those of the same condition in the adult. In forms of broncho- 
pneumonia or catarrhal pneumonia in which areas of considerable 
extent are consolidated the signs will closely resemble those obtained 
in the fibrinous form. The physical signs of lobar or fibrinous 
pneumonia are classified as those of the first, second, and third stages 
of the disease. 

First Stage, Stage of Engorgement of the Lung. — On inspection 
the signs of dyspnoea above noted are found. 

Palpation at this stage will in an uncomplicated case give no 
signs, even over the affected area. If bronchitis complicates the 
case, rhonchal fremitus may be obtained. At this stage the differ- 
ence in fremitus between the affected and the unaffected side of the 
chest is not perceptible. 

Auscultation. — In the first stage of the disease auscultation 
may discover a rude respiratory murmur on the healthy and diseased 



574 DISEASES OF THE RESPIRATORY SYSTEM. 

sides which is more marked in the latter and on inspiration. The 
pathognomonic sign at this stage is the crepitant rale, which is 
sometimes easily found and is at others very elusive. It may be 
present before an attack of coughing, and disappear after the bronchi 
have been cleared, and is, as a rule, heard over a very limited area. 
It is therefore necessary to examine the chest very carefully in front, 
behind, and in the axillary line for this sign, before deciding posi- 
tively as to its presence or absence. It may be present for a few 
hours only. 

Percussion will at this period give slight dulness over the 
aifected area of lung. The dulness may be slightly tympanitic. 
This is caused by the fact that at the outset of consolidation there 
is still some air in the affected area. Under these conditions there 
may be what is known as tympanitic dulness. This condition is 
especially found in young infants, in whom the chest-wall is thin, 
and in whom sounds are very well obtained by gentle percussion. 

The Second Stage, Stage of Consolidation. — If the lower portion 
of the right lung is affected, we shall get by palpation in front over 
the upper part of the chest nothing abnormal ; over the lower part 
of the chest in front there will be an increase of the vocal fremitus, 
which is also apparent behind. Percussion over the upper part of 
the right lung will give a vesiculotympanitic note in front and 
behind. The unaffected side will give normal pulmonary resonance. 
In exceptional cases the percussion-note over the upper lobe of the 
lung in front may give the so-called cracked-pot sound. In front, 
behind, and in the axillary line over the lower lobe whicli is affected 
there is dulness — not at first complete. When consolidation is com- 
plete, the dulness is quite marked. In cases in which some pleuritic 
effusion exists over the consolidated area behind, the percussion-note 
may be quite flat. In cases in which the upper lobe is consolidated 
there will be signs of consolidation, while lower down the note is 
exaggerated or vesiculotympanitic over the unaffected mid-region of 
the lung, and over the base there will also be marked dulness. This 
lower area of dulness should not be regarded as a sign of consoli- 
dation. It is really due to the accumulation of a small amount of 
serous effusion in the lower part of the pleural cavity as a result of 
the complicating pleurisy. 

Auscultation will in this stage give bronchial voice and breath- 
ing over the affected area of the lung ; over the unaffected lung the 
respiratory murmur, especially the inspiratory sound, is harsh. This 
harsh inspiratory sound is quite common in children, and is fre- 
quently mistaken for bronchial breathing. Bronchial breathing is 
tubular in quality on inspiration and expiration. In this stage, if 
the upper lobe of the lung is also involved and there is some pleuritic 
effusion in the chest, the respiratory murmur may be much weakened 
over the lower region of the chest behind, 



LOBAR PNEUMONIA. 575 

The voice also has a tubular or bronchial quality over the con- 
solidated area. The intensity of the voice may be diminished over 
the lower portion of the chest if pleuritic effusion is present with 
consolidation of the upper lobe. Pleuritic rales may in this stage 
be heard over the whole side of the chest. 

Third Stage. — The third stage, that of resolution, is sometimes 
delayed, some days elapsing after the crisis before appearance of the 
sign pathognomonic of this stage — the so-called rale redux. This 
rale has the same qualities as that heard in adults at the same stage. 
In children it is sometimes present for only a short time, and is not 
heard over any considerable area of the lung. I have known the 
temperature to be subnormal for two days or more before its appear- 
ance. The other sign, which is less important, is a distinct diminu- 
tion of the fremitus until it reaches the normal intensity over the 
affected area of lung. The percussion-note becomes less dull, 
assuming the vesiculotympanitic quajity. Repeated auscultation 
reveals, in addition to the rale redux, a gradual return of the voice 
and breathing to the normal, which sometimes takes weeks. The 
tubular quality of the voice and breathing over the affected area 
of lung may persist long into convalescence. It is probably not 
caused by any actual persistence of consolidation, but by a con- 
tinued hypersemia of the lung. The lung under these conditions is 
denser and conducts sounds from the bronchi with greater intensity 
than the healthy lung. If pleurisy has been present to any extent, 
there may, after the disappearance of the signs of consolidation, be 
signs of dry pleurisy or those of effusion. 

Pneumonia of an Unusually Short Course. — Leube and Weil have 
recorded in the adult typical pneumonia of the fibrinous variety 
and of very short duration. Some of these cases exhibit the chill, 
fever, pain, and crisis, with other signs of physical involvement 
of the lung, within twenty-four to thirty-six hours. Jiirgensen has 
recorded short lethal pneumonias of the fibrinous variety in the 
adult. The cases of Levy and Jiirgensen were fatal within twenty- 
four to thirty -six hours. I have never met such cases of fibrinous 
pneumonia in children, but have seen lobar pneumonia with a history 
of short duration (Fig. 112). In cases running a very short course 
there is doubt as to whether the signs obtained over the chest may 
not have been connected with a preceding attack. Henoch has, 
however, met a few cases which ran a rapidly fatal course, with the 
whole symptomatology of lobar pneumonia including physical signs, 
in forty-eight hours. 

Complications. — Among the complications of fibrinous pneumo- 
nia in infants and children are otitis, pleurisy, pericarditis, endocar- 
ditis, empyema, and meningitis arthritis and osteomyelitis. Some 
writers record peritonitis ; I have not met a case. Gastro-enteritis 
is quite a common complication. 

Otitis is common, its frequency varies in different epidemics. 



576 



DISEASES OF THE RESPIRATORY SYSTEM. 



It affects younger children and infants more frequently than older 
subjects. The temperature in these cases becomes more markedly 
remittent and remains higher for a greater length of time than in the 
uncomplicated cases. I have frequently suspected otitis from a study 
of the temperature-curve, which is not, however, an altogether 
reliable guide. Suppuration in the pleura will give a similar curve. 
Therefore, in a concrete case of persistent high temperature-curve 
with morning remissions, otitis should be suspected, but not posi- 
tively diagnosed without careful exclusion of other complications. 

Fig. 112. 



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Lobar pneumonia, midregion of the right lung ; crisis on the fourth day of disease. Boy, 
seven years of age. (Author's case.) 

Otitis as such does not seem to give any striking symptoms of pain. 
The patient may without warning present perforation of the drum 
of one or both ears and a purulent discharge. The temperature 
will then fall to the normal. Diplococcus pneumoniae has been found 
by a number of observers in this discharge. The otitis is of a benign 
nature. 

Meningitis occurs in a number of cases, and may usher in the 
disease. I have seen it persist for weeks. The prognosis in this 



LOBAR PNEUMONIA. 



577 



form of meningitis, if it assumes the cerebrospinal type, is graver 
than when it occurs as a primary disease, with the intracellular dip- 
lococcus of Weichselbaum as a causative factor. Netter seems to 
have met a larger number of cases of the pneumococcus form of 
meningitis than any other author. The cases of meningitis compli- 
cating pneumonia should not be confused with those presenting cere- 
brospinal symptoms. The cerebrospinal symptoms seen at the outset 
or at the crisis in some cases of pneumonia do not last for any great 
length of time, and do not present the true symptoms of meningitis. 
Pleurisy and Empyema. — Many cases of fibrinous pneumonia show 
a dry pleurisy sometimes persisting for a long time after convales- 
cence. Of greater moment are the cases of pleurisy with effusion, 
which follow a lobar pneumonia. In these, there is always the danger 
that the exudate may eventuate in an empyema. The duration of 
the exudate is no guide in determining whether it is of a serous or a 
purulent nature. It is frequently found that after a pneumonia has 
run its course the temperature remains raised a degree or more 
toward evening. Such a rise in temperature may, in the absence of 
signs of fluid, indicate a dry plastic pleurisy (Fig. 113). On the 
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Lobar pneumonia, lower lobe, left lung ; complicating pleurisy ; temperature falling grad- 
ually to the normal. Leucocyte count indicated. Boy, five years of age. 

shows irregularities of rise, empyema may be present. I have met 
empyema without any rise of temperature in infants who showed 
the physical signs of fluid in the chest. These points will be more 
fully discussed under the head of Empyema. 

Pericarditis. — I have seen pericarditis in infants who died of 
a fibrinous pneumonia, but the diagnosis was not made during 
life. Von Jaksch notes such cases. In older children, pericarditis 
is a complication found in cases of fibrinous pneumonia which 

37 



578 mSEASES OF THE RESPIRATORY SYSTEM. 

have simultaneously developed empyema. Such cases are very 
uncommon. In the form of pericarditis which I have seen in 
infants, the quantity of effusion has not been sufficiently great 
to enable a diagnosis to be made with certainty, and the rales 
in the lung obscured the friction-sounds in the pericardium if they 
were present. Purulent pericarditis in these subjects is very fatal 
under such conditions. In older children I have seen pneumonia 
combined with a fibrinous pericarditis pure and simple, without fatal 
issue. 

The prognosis of lobar pneumonia varies within certain limits. 
Text-books give statistics taken from hospital cases, notably the 
most unfavorable material. Henoch gives the mortality of his cases 
at 5 per cent. ; Baginsky, at 8 per cent. ; Holt, at 1 2 per cent. ; my 
own hospital cases during the past year showed a mortality of 8 per 
cent. On the other hand, in private practice death from an acute 
fibrinous pneumonia rarely occurs in a child previously healthy and 
living in good surroundings. The mortality is influenced by the 
season of the year, being greater from December to February, and 
by the presence of an epidemic. If pneumonia is prevalent during 
an epidemic of influenza, the mortality will increase. Pericarditis or 
complicating empyema influence the death-rate. The previous con- 
dition of the patient, the mode of feeding (whether by the breast 
or the bottle), and a rachitic or marantic condition, affect the prog- 
nosis. The age of the patient is also an important factor. Infants 
under one year of age are in greater danger than older ones. The 
prognosis is best from the third to the tenth year. The younger 
the bottle-fed baby, the more serious the complication of empyema. 
In making a prognosis in any concrete case, the physician should be 
guided by the extent of lung involvement and the general condition 
of the circulation. If one lobe alone is involved and there is an 
absence of bronchitis in the uuaff'ected lung, the outlook is good. 
If the heart action is good and there is an absence of cyanosis, 
recovery can be predicted even if the temperature be high. If, on 
the other hand, the lysis or crisis is delayed and the dulness or flat- 
ness involves a whole side of the chest, in the presence of signs of 
a Aveak heart the prognosis should be made with caution. Menin- 
gitis of pronounced type is grave. Pericarditis in young infants 
and children is a complication invariably fatal. Where facilities exist, 
a leucocyte-count should be taken every second day, accompanied by 
a differential count of leucocytes. A very low leucocyte-count, with 
marked signs of pneumonia and a high temperature, is a grave prog- 
nostic sign, though such cases may recover. On the other hand, a con- 
tinued high leucocyte-count, as has been pointed out, may be present 
with extensive inflammation of both lungs, and death may ensue. 

The diagnosis of lobar pneumonia in infancy and childhood 
ordinarily presents few difficulties, but is not easily made if in addi- 
tion to the pneumonia there is an eff'usion in the chest. The diag- 



LOBAR PNEUMONIA. 579 

nosis should never be made early in the disease without positive 
signs. 

The crepitant rales sometimes escape observation. The physician 
should then wait for the appearance of dulness or bronchial voice 
and breathing before arriving at a conclusion as to the presence or 
absence of consolidation. Cases of influenza with a harassing cough 
are frequently diagnosed as central pneumonia. A pneumonia which 
is central will give physical signs. If after the time set for the 
crisis or lysis, the temperature persists and becomes remittent, careful 
examination should be made for evidences of fluid in the chest. The 
nature of the fluid should be determined by exploration with the 
aspirating needle, if the fever does not subside and if the dyspnoea 
increases. A chest effusion in infants and children is apt to be 
purulent. 

The cerebral cases present difficulties of diagnosis. Convulsions, 
delirium and rigidity of the neck, accompanied by high fever and a 
cough, with increase of the pulse-rate and the number of respirations, 
indicate the necessity of making a very careful examination of the 
chest. 

In cases which begin with a lobar pneumonia, typhoid fever may 
be suspected if, after the first days of illness, a roseola or an enlarge- 
ment of the spleen develops with a continuance or gradual rise of 
temperature. In such cases the presence of an epidemic of typhoid 
fever and the Widal blood reaction will be of service in clearing up 
the diagnosis. 

The treatment of lobar pneumonia is pre-eminently expectant. 
The disease is self limited, and complications cannot be prevented. 
The temperature should be treated within certain limits, and the 
heart and the strength of the patient supported. The temperature 
should be treated not with a view to its actual reduction, but in 
order to mitigate its ill effects. Infants and children will be less 
affected by a temperature of 103° F. (39.4° C.) lasting during the 
time while a pneumonia runs its course than by the same tempera- 
ture in typhoid fever. The toxaemia of pneumonia is of a more 
benign character. Cold applications are relied on to reduce the 
temperature. 

Hydrotherapy. — Sponging is efficient in cases in which the tem- 
perature does not generally range above 104° or 104.5° F. (40° C). 
The younger the infant the less energetic need it be, for a tempera- 
ture of 104.5° F. (40° C.) is not high for an infant under two years 
of age. I content myself with sponging of the body with water at 
80° F. (26.6° C), to which some alcohol has been added. If the 
temperature remits a degree or more during the twenty-four hours, 
there will be less need of sponging. The temperature should 
never be taken more often than every three hours. If it is above 
103.5° F. (39.7° C), the patient is sponged for fifteen minutes and 
then given absolute rest for three hours. Frequent sponging is 



580 DISEASES OF THE RESPIRATORY SYSTEM. 

pernicious. Some infants when sponged with water at 80° F, 
(26.6° C.) become blue, the pulse becoming rapid and thready. With 
these subjects a warm bath at a temperature of 105° to 107° F. 
(40.5° to 41.6° C.) is stimulating. It supports the strength and cer- 
tainly lessens the ill effects of the temperature, although it may not 
reduce it palpably. I do not use the full cold bath in the treatment 
of lobar pneumonia in infants and children. If the temperature 
reaches 105°-106° F. (40.5°-41.1° C), a full bath of the tempera- 
ture of 85°-90° F. (29.4°-32.2° C.) or higher may be given, cer- 
tainly never lower. 

One of the most useful methods of hydrotherapy in the treatment 
of pneumonia in young infants is the so-called chest compress 
(page 61). These compresses renewed every hour will cause the 
restlessness to diminish, the heart action to improve, and the patient 
to fall into a quiet slumber. The actual reduction of temperature 
is not so marked as the favorable effect on the general condition of 
the patient. The application of compresses is discontinued if the 
temperature falls below 103° F. (39.4° C). 

Medicinal Treatment. — The heart action if good needs no atten- 
tion. At most, a limited amount of wine or whiskey is administered. 
Infants may receive half a drachm (2.0) every few hours ; older 
children, a drachm (4.0). Whiskey should not be given as a routine 
remedy. If the temperature is high necessitating hydrotherapy, 
and the pulse is above 120, whiskey should be given. If the pulse 
is high, 150—160, a few minims of the tincture of digitalis may be 
given to older children. Younger children rarely need more than 
half a minim every two to three hours. If the pulse-rate is reduced 
after the administration of digitalis, the drug should be discontinued 
before the pulse drops below 100. There is no doubt that its effect 
is more cumulative in some subjects than in others. 

Strychnine is of value in the treatment of pneumonia, not so 
much in the cases with rapid as in those with slow and irregular 
pulse. Infants will bear grain -^-J-g- to y^ (0.0003 to 0.0004) every 
three hours, for days. 

Caffeine is of great value in the treatment of irregularities of the 
heart which indicate a myocarditic process. The pain is the result 
of a pleuritic process. 

The local application of iodine or mustard paper is an efficient 
counter-h-ritant. If the cough is troublesome, codeine in moderate 
dosage is the most useful remedy. 

I never make use of morphine with infants and children. In 
young infants the milder preparations of opium, such as camphorated 
tincture or the wine, are most useful. Four minims (0.25) of the 
camphorated tincture of opium every two or three hours will be 
found efficient in children under two years of age. To older children 
a small dose of codeia may be given several times daily if needed. 
The aim is to alleviate the pain and cough. 



BRONCHOPNEUMONIA. 581 

The bowels should be evacuated daily ; for this purpose hydrarg. 
cum creta is one of the best remedies. Grain v (0.3) may be given. 
Infants should receive an enema daily. If gastro-enteric disturb- 
ances ars present, the giving of milk should be discontinued and the 
same procedure followed as in primary gastro-enteritis. 

Tympanites is sometimes troublesome, especially in young chil- 
dren. The best remedy is a high enema twice daily of salt solution, 
to which one or two teaspoonfuls of peppermint-water have been 
added. The passage of a soft catheter is not effective, nor are the 
turpentine stupes of any value. 

The delirium, sometimes amounting to an acute mania, which 
appears just before the crisis in some cases, is best controlled by 
rectal administration of bromide of potassium and chloral hydrate. 
I have sometimes been forced to keep the patient under the influence 
of these drugs for a few days. The post-pneumonic melancholia 
seen in children is best treated by the administration of strychnine 
and the enforcement of perfect quiet. 

Should signs of extreme cardiac weakness set in with threatening 
oedema of the lung and paralysis of the right ventricle, nitroglycerin 
is of great value. Infants will bear grain ^-^ (0.0003) every three 
hours. If in these cases cyanosis is present, oxygen is administered, 
preferably that containing 20 j)er cent, of nitrous oxide. It is given 
to infants, every half hour for five or ten minutes at a time by 
means of a cone. 

Hygiene. — The patient should be isolated if possible. The room 
should be ventilated and its temperature kept at 68°-72° F. (20°- 
22.2° C). 

The sputum should be received in pieces of gauze, which are 
burned. The mouth and teeth should be cleansed twice daily with 
a piece of soft linen and a solution of boric acid. In the intervals 
between feedings the tongue is kept moist by frequent draughts of 
water. 

Bronchopneumonia. 

{Catarrhal Pneuvwnia, Lobular Pneumonia.) 

Bronchopneumonia is the prevalent type of pneumonia occurring 
before the fifth year, but there are also many cases of lobar fibrinous 
pneumonia during the periods of infancy and early childhood. 

Bronchopneumonia occurs both as a primary and a secondary 
disease. As a primary disease it is most frequent during the first 
two years of life. Of 605 of my cases of bronchopneumonia, the 
incidence in regard to age was as follows : 



One to three months . . 32 

Three to six months 68 

Six to twelve months 207 

One to two years 298 



582 DISEASES OF THE RESPIRATORY SYSTEM. 

These figures correspond within certain limits to those of other 
authors, although Holt places the greatest frequency between the 
sixth and the twelfth months. 

Sex. — Of the 605 cases, 322 were males — a statement corre- 
sponding to that of Jiirgensen in regard to lobar pneumonia. 

Season. — The greatest frequency is during the winter months, 
when there are epidemics of influenza during which many primary 
and secondary cases of bronchopneumonia occur. 

Surroundings. — The herding together of the poor certainly has 
a tendency to increase the prevalence of bronchopneumonia among 
them. If we believe in the epidemological aspects of pneumonia, it 
is easy to account for the greater frequency of the disease among the 
poor : the greater number of their children are rachitic, syphilitic, 
marantic, and ill-fed, and thus have increased susceptibility to in- 
fection. 

Secondary bronchopneumonia occurs as a complication in the 
exanthemata (measles, scarlet fever, typhoid fever), diphtheria, per- 
tussis, and influenza. By far the greater number of cases occur as 
a sequence of ordinary bronchitis. 

Etiology and Bacteriology. — Weichselbaum first demonstrated 
that the pneumococcus of Frankel could cause primary broncho- 
pneumonia. His results have been confirmed by Cornil, Babes, 
and Neumann, the latter of whom found the pneumococcus in cases 
of primary bronchopneumonia. Quesiner and Neumann found the 
pneumococcus in the sputum of children suffering from broncho- 
pneumonia. 

The secondary form of bronchopneumonia may be caused by 
streptococci (Northrup and Prudden), which invade the lung-tissue 
from the trachea, as in diphtheria. Guarnieri also found streptococci 
in the lungs of children dying with bronchopneumonia after measles. 
On the other hand, these secondary types of bronchopneumonia may 
also be caused by the pneumococcus of Frankel, which causes the 
primary type of the disease. This has been shown in the work of 
Netter on the subject, and confirmed by Banti, Strelitz, and Baginsky. 
In diphtheria the Klebs-Loffler bacillus may be foujid in the lung 
areas of secondary bronchopneumonia (Babes, Frosch, Baginsky). 
The Eberth bacillus has been found in areas of bronchopneumonia 
complicating typhoid fever (Polyniere). 

Morbid Anatomy. — The essential lesion in bronchopneumonia is 
an inflammation of the walls of the bronchi and of the air-spaces 
surrounding the inflamed bronchi (Delafield). The walls of the 
bronchi are thickened and infiltrated with small round cells ; those 
of the alveoli of the lung are thickened and their cavities filled with 
fibrin, pus, epithelial cells, and new connective tissue. The smaller 
bronchi are dilated and contain pus, their walls being infiltrated. 
The inflammation may also be conveyed from the bronchi to the 



BRONCHOPNEUMONIA, 583 

parenchyma of the hmg by aspiration of secretion (Ziegler). In the 
latter case the smaller bronchi are occluded, collapse of the lung 
follows (atelectasis), and a pneumonia thus results. On section there 
are seen grayish-red, gray, or yellowish-gray areas of varying con- 
sistency, which correspond to a cut bronchus and its surrounding 
peribronchitic pneumonia. If the areas are croupous, they have a 
more granular appearance. Small areas of this form of pneumonia 
may coalesce, and thus whole lobules of the lung be consoli- 
dated. These larger areas may be separated by lung-tissue which 
contains air, or a whole lobe may become consolidated, as in lobar 
pneumonia. The exudate found in the affected alveoli is at first 
composed of desquamated swollen epithelial cells, and later of 
leucocytes. If the exudate has a more fluid character, it is called 
catarrhal. It then contains more serum than fibrin. If the fibrin 
is in excess, the exudate has greater consistency, resembling that in 
lobar pneumonia, and is then called croupous. The catarrhal and 
croupous forms of exudate may both exist in a lung afi'ected with 
bronchopneumonia. Blood-cells may predominate in the exudate, 
so that the lung may on section have a hemorrhagic appearance. 
This is apt to be the case in streptococcus inflammation and also if 
foul fluids have been aspirated. 

The mucous membrane of the bronchi is the seat of catarrhal 
inflammation. 

There is inflammation of the pleura to a varying degree. 

The bronchial and mediastinal lymph-nodes may be enlarged 
with simple or tuberculous inflammation. There is oedema of the 
lung tissue which is not inflamed. Bronchopneumonia may result 
in resolution and restoration to the normal. Suppuration and for- 
mation of abscess with destruction of lung tissue, or gangrene of 
the lung, may result in rare cases. 

Persistent bronchopneumonia in children results in induration of 
the lung. There is an increase of the connective tissue of the 
alveolar septa, of the walls of the smaller and larger bronchi, and 
also of the walls of the peribronchial vascular tissue. The lung on 
section is seen to be studded with fibrous nodules, or a whole lobule 
or lobe may be converted into connective tissue. 

Symptoms. — Bronchopneumonia is divided clinically into sev- 
eral distinct types. In newly born and very young infants the 
disease may set in insidiously. The infant is born in good con- 
dition ; after some little exposure it develops slight snuffles and a 
slight cough. Dyspnoea then appears. All this may occur within 
the first eight days after birth. The cough becomes more harass- 
ing and the dyspnoea more marked. Slight cyanosis supervenes 
after a time. The infant is restless and does not sleep, the cyanosis 
becoming more marked and constant. The infant may have fre- 
quent convulsions. The dyspnoea finally becomes so marked as to 



584 DISEASES OF THE RESPIRATORY SYSTEM. 

cause distinct drawing inward of the lower part of the chest-wall 
with each inspiration. In these cases there is little or no tempera- 
ture ; in that respect they resemble cases of bronchopneumonia in 
extremely old people. The temperature may be slightly subnormal 
even when the infant is mortally ill with a disseminated broncho- 
pneumonia. The cough may not be marked. These cases should be 
differentiated from those occurring in infants born with an atelectatic 
condition of the lungs. In the class of cases under consideration, 
atelectasis develops as a sequence of the bronchitis and broncho- 
pneumonia. The movements are greenish, containing undigested 
curds. The infants may finally develop enteritis. The course of 
the disease is in these cases very acute. The infant either rapidly 
grows worse or begins to improve immediately. The former course 
is, however, the rule in this very dangerous and insidious form of 
bronchopneumonia. If the infant does not improve, the cyanosis 
becomes more marked, as does also the dyspnoea ; the respirations 
increase to more than 80 a minute, the pulse becomes very rapid, and 
the heart feeble ; the infant lies in a soporose state ; the end may 
supervene with tympanites, convulsions, and oedema of the lung. 
This form of bronchopneumonia is very frequently overlooked at 
the outset and mistaken for a simple bronchitis. 

Another form of bronchopneumonia in infancy begins as a 
simple bronchitis, and may be treated as such for days. Finally, 
posteriorly in both lungs there are found the fine crepitations 
which give warning of the presence of bronchopneumonic pro- 
cesses. Bronchopneumonia of this variety runs its course without 
temperature. It occurs in rachitic or weakly infants and children, 
or follows a mild attack of influenza. The attacks of coughing 
are especially troublesome, and are frequently followed by vomit- 
ing of the contents of the stomach. The movements are loose, 
and show greenish particles and undigested white flaky masses. 
The dyspnoea is constant and characteristic, and if the patient is 
out of bed, grows more marked toward the late afternoon. The 
alse nasi are dilated. The temperature rarely rises above 
101° F. (38.3° C), and is generally 100° F. (37.2° C.) or even 
lower. The course is favorable ; the cough may persist for weeks 
after the subsidence of the acute symptoms, being especially marked 
at night. 

A more common form of bronchopneumonia in infancy begins 
as a simple bronchitis, which may last for a few days, when, with- 
out warning, the infant has a chill followed by a rise of tempera- 
ture, the case having suddenly developed into a full broncho- 
pneumonia. In a six weeks' old infant with disseminated patches 
of pneumonia, the chill was so severe as to cause extravasations 
of blood underneath the surface, with markings resembling those 
seen in marbling of the surface. In another case the chill was so 



BR ONGH OPNE UMONIA . 



585 



severe that an immediate fatal issue was feared. In that broncho- 
pneumonia sometimes begins with a chill, it resembles a lobar process. 

The most common type of bronchopneumonia may begin with 
a rise of temperature preceded by vomiting. The harassing cough 
is present from the outset, causing the patients to cry with pain at 
each attack. There is no sputum, but in very young infants a 
frothy mucus may in the later stages of the disease collect about 
the mouth. The dyspnoea is marked. The alse nasi are dilated 
at each inspiratory effort. The peripneumonic groove is depressed, 
and in very severe dyspnoea the suprasternal region may also be 
depressed at each inspiration. Very frequently the dyspnoea will 
resemble that due to laryngeal stenosis. There are, however, 
none of the signs of laryngeal obstruction, such as laryngeal 
breathing. 

Fever is always present in infants and children, except in the 
classes of cases above noted. It may reach 106° F. (41.1° C), and 
is as a rule remittent. It may fall gradually to the normal, and in the 
favorable cases may reach the subnormal and remain there for a 
few days. The course of the fever is, however, not an indication 



Fig. 114. 


USnth Jan. 4 5 6 7 8 10 


3 4 5 6 7 8 9 


HOUR 369 12 369 12 369 12 369 12 369 12 369 12 3t)9 12 369 12 369 12 369 12 369 12 369 12 369 12 369 E 

i-MmnMEmM HUM 


s"eeeeeeeeeeeeeeeee;eee3=eeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeee 

"pulse g 5 22232 S iS gsSisgiS S 3 


RESP. sgg s??s S3sss?ssss§ ss| sf-'g|sgss E2 ggsss sssss; gg 



Fatal bronchopneumonia ; reinvasion of the lung on the fifth day. Infant, six months old. 

of the severity of the disease. Fatal bronchopneumonia sometimes 
shows a steady decline in the temperature toward the approach of 
the fatal issue. In other cases the temperature may drop to the 
normal, remain there a few hours or a day, and then rise sharply to 
104° F. (40° C.) or higher, thus indicating that a new part of the 
lung has been invaded by the disease (Fig. 114). Such rises of 
temperature after a fall to the normal are of grave import if they 
occur in an infant acutely ill with a process which has been severe 
for days. They show a tendency of the process to spread, and in 
young weakly infants such an extension of the process is apt to 
be fatal. A drop by lysis to a normal temperature which con- 



586 



DISEASES OF THE RESPIRATORY SYSTEM. 



tinues for a few days, and is followed by a slight gradual rise with 
subsequent remissions to the normal is also common, and may 
indicate a retura of the bronchopneumonic process, or a pleuritic 
effusion of a purulent character. The physician should be on the 
alert for an effusion in the cases which have run an irregular or 
remittent temperature for a period of more than two weeks. I 
have, however, operated upon cases of empyema following broncho- 
pneumonia in infants, in which the temperature-curve was normal for 
days, and then showed occasional rises to 101° or 102° F. (38.3° 
or 38.8° C). 

The pulse is as a rule rapid. It is difficult in infants to estimate 
its exact character. It is, however, always possible to distinguish 
the abnormally weak and thready pulse even in the youngest infant 































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Ordinary type of bronchopneumonia. Recovery. 

of age. 



Female child, one year and six months 



The rapidity of the pulse varies widely even in the favorable cases. 
Its ratio to the respiration (the pulse-respiration ratio) is, as a rule, 
maintained in favorable cases, but is not always so. Even if it be 
so much distorted as to present the ratio of 1 to 2, the patient 
may make a good recovery. The character of the pulse and respira- 
tion should therefore be judged in connection with other signs of 
decreasing heart power, such as abnormal pallor, coldness of the 
surface, and cyanosis however slight. In artificially-fed in flints 
who are above the average weight, the beginning of cardiac weak- 
ness is indicated by an abnormal pallor of the face and slight cya- 
nosis of the lips. 

Sputum. — In young infants there is no sputum, nor is it probable 
that in uncomplicated cases of bronchopneumonia the younger in- 
fants cough up and swallow sputum, as is generally supposed. At 
most, there is after severe attacks of coughing a collection about 
the lips of frothy mucus probably coming from the trachea. 

Gastro-enteric Tract. — The symptoms referable to the stomach and 



BUONCHOPNEVMONIA. 587 

intestine are of great importance in severe bronchopneumonia of 
the primary type. Even up to the second year of life tympanites 
sets in very early. In one case it was so distressing a symptom 
as to mislead the physician into thinking that peritonitis might be 
present. It is especially apt to set in with rachitic and w^eakly in- 
fants who have been fed on the bottle. If it appears late in a very 
sick infant, it is a symptom of grave import, and may sometimes 
cause the fatal issue. In some cases the pre-agonal distention is very 
extreme, and so far as can be judged very painful. Some infants 
begin to vomit from the outset of the pneumonia. The vomiting 
may occur once or twice in the twenty-four hours, or may be inces- 
sant. With the vomiting there may be the passage of greenish stools 
or a fully developed enteritis of severe type. So severe is the en- 
teritis in some cases as to cause the death of a patient suffering from 
pneumonia of only moderate severity. This form of the disease 
does not occur exchisively in the summer months, but is more preva- 
lent at that time. 

Cerebral Symptoms. — The infant is in some cases stupid from the 
outset of the disease. Older children may have slight convulsive 
twitchings of the muscles of the face and extremities. In cases in 
children at the third year there may be complete unconsciousness 
and symptoms simulating those of meningitis, such as rigidity of 
the muscles of the neck. I have seen the cerebral symptoms persist 
for weeks in young infants who made complete recoveries. In other 
cases in young infants and children, the bronchopneumonia may 
partly resolve, and still there may be a continuance of the cerebral 
symptoms or even an exacerbation of them. In these cases the 
possibility of the presence of otitis or mastoid inflammation should 
be seriously considered. 

The secondary form of bronchopneumonia may complicate the 
exanthemata — measles, scarlet fever, varicella, typhoid fever, per- 
tussis, influenza, and diphtheria, and also gastro-enteritis or any form 
of infection, such as that of septic wounds or osteomyelitis. 

The symptoms of bronchopneumonia which complicates pertussis 
are of an unequivocal character. A febrile movement may be present 
with a simple bronchitis. If bronchopneumonia is imminent or 
present, the fever is marked and constant, and may reach 106° F. 
(41.1° C). The dyspnoea is very marked, but the cough may not 
be increased. In certain forms of pertussis without complications 
there is a slight constant dyspnoea, which is due to the disease. If 
bronchopneumonia is a complication the dyspnoea is more decided, 
the number of respirations three or four times the normal, and the 
pulse-rate increased. There is marked cyanosis. There may be all 
the symptoms of a severe bronchopneumonia, such as tympanites, 
vomiting, and green diarrhoeal stools. The bronchopneumonia is, 
as a rule, of the disseminated type, with areas of consolidation of 



588 DISEASES OF THE RESPIRATORY SYSTEM. 

greater or lesser extent in both lungs. The infants are much more 
ill than they would be with a primary process of the same extent. 
A bronchopneumonia of this kind can be diagnosed if upon exami- 
nation of the chest there are, in addition to the physical signs of 
bronchitis, fine crepitations over the different parts of the chest, 
especially over the lower lobes of both lungs posteriorly. There 
may also be dulness with bronchophony and bronchial breathing over 
small areas, either in the npper or lower lobes of the lung on one or 
both sides. The bronchopneumonia of pertussis may supervene at 
any period of the disease, and is not the result of exposure. On 
the contrary, it may occur in infants and children who have been 
most carefully protected from exposnre. It is the result of the form 
of disease — a mixed infection. The pertussis probably makes the 
lung more viable to disease in some subjects than in others. The 
bronchopneumonia is a grave complication, and is very fatal. It 
may cause complications, such as pleurisy of a serous or purulent 
nature, and often opens the way for invasion of the lung by tuber- 
culosis. It may run a chronic course (persistent pneumonia) and 
reduce the patient to a very weak state. The patient will then 
develop consolidation of a whole lobe of the lung which will take 
weeks to clear up. 

Bronchopneumonia complicating measles supervenes, as a rule, in 
the stage of eruption, and is a very serious complication. Its pres- 
ence may be suspected if, on examination, of the chest, there are 
found, in addition to the rales of bronchitis, very fine crepitant rales 
over areas disseminated through both lungs. This complication also 
causes a febrile movement after the fading of the eruption. There 
are severe cough and dyspnoea. The pulse may reach 180 to 190, 
and the respirations 90, but the patient may recover even if the 
signs of cardiac weakness, such as cyanosis, are marked. The 
patient is stupid, does not take food or notice his surroundings. 
Sometimes there may be other signs, such as hemorrhages into the 
eruption (so-called hemorrhagic measles), indicating that the process 
is one in which there is a mixed infection. There may be a com- 
plication of serous or seropurulent pleurisy. 

Bronchopneumonia complicating typhoid fever does not, as a 
rule, give very striking features apart from those belonging to the 
latter disease. It seems to be of a mild and insidious character. 
The bronchopneumonia of typhoid fever is apt to mask the typhoid 
if it appears at the outset of the disease. There is then a typhoid 
beginning as a pneumonia. The area of bronchopneumonia is well 
localized. It may be a small area in the upper or mid-region of the 
lung. The febrile curve in these cases may range quite high at the 
outset and thus mislead the physician. The process persists for 
weeks, sometimes as long as five weeks. The lung is slow in clear- 
ing up. The signs of dulness, bronchial voice and breathing may 



BRONCHOPNEUMONIA. 589 

persist into convalescence. In other cases the pneumonia may 
supervene in the course of the disease. It can then be detected 
only if the cough is harassing and the dyspnoea marked. In deliri- 
ous patients the pneumonia can only be discovered by repeated and 
constant examination of the chest. These cases are not so apt to 
develop pleurisy of a serous or purulent nature as the pneumonia 
complicating measles or scarlet fever. 

Varicella is only rarely complicated by bronchopneumonia. In 
this disease also the pneumonia runs a protracted course, but is less 
serious in its outcome than in the other exanthemata. It occurs in 
the severer forms of varicella in which the eruption is complicated 
with abscesses or necrosis of the skin (mixed infection). 

Scarlet fever is not so frequently complicated by bronchopneu- 
monia as measles, but when it does occur the bronchopneumonia is 
of a very severe type. It occurs in the septic forms of scarlet fever, 
and may appear early in the disease, on the fading of the eruption. 
Scarlet fever complicated by bronchopneumonia is frequently followed 
by pleurisy of a purulent nature. 

The bronchopneumonia which complicates diphtheria has been 
carefully studied by Northrup and Prudden. It is the result of 
a streptococcic invasion of the lung or an invasion by the Klebs- 
Loffler bacillus. As a rule, however, it is a mixed infection, 
as was pointed out by Northrup and Prudden. The laryngeal 
form of diphtheria frequently proves fatal through this complica- 
tion. 

Of special interest is the bronchopneumonia which complicates 
chronic or subacute diarrhoeal conditions. This form, which is of 
a distinctly septic type, is caused by infection of the lung by strep- 
tococci, which invade the general circulation through erosions in the 
mucous membrane of the gut (Booker, Czerny, Fischl). It is not 
always due, as was formerly supposed, to keeping the infant in the 
recumbent posture, nor does it occur in hospital practice alone, 
but is frequently seen in private practice in infants in unhygienic 
surroundings. It is of the persistent type, and runs its course with 
a daily high or low febrile curve, and results in areas of consolida- 
tion, which sometimes involve a whole lobe of a lung. This form 
of pneumonia is one of the fatal complications of the subacute intes- 
tinal catarrhs. 

Some infants, after one attack of bronchopneumonia, have repeated 
or recurrent attacks on the least exposure (Fig. 116), in some cases 
developing catarrhal croup. In other cases, there develops an em- 
physematous condition of the lung, in which the least exposure or 
change in the atmosphere will cause an asthmatic attack. 

Course, Termination, and Complications. — Bronchopneumonia 
may terminate in complete recovery and restoration of the lung to 
the normal, or may prove fatal. The mortality varies at different 



590 DISEASES OF THE RESPIRATORY SYSTEM. 

times and with the environment. The prognosis in marantic infants, 
and also in bottle-fed infants, is very bad. Rachitic infants have 
bronchopneumonia with a very protracted course (Fig. 117). The 
forms which complicate measles, pertussis, scarlet fever, and influ- 
enza are very fatal. Abscess or gangrene of the lung may be a com- 
plication. In some forms of otitis the symptoms may very closely 
simulate those of tuberculous meningitis. Otitis prolongs the disease 
and frequently misleads the physician. Especially trying are the 
forms of bronchopneumonia of very limited extent in one or both 
lungs, in which, after the disease has run its course, there is a pro- 
tracted, remittent or intermittent fever-curve. Serous pleurisy and 
empyema are very common complications. Their presence may be 
suspected if the disease runs a course protracted beyond two weeks, 
and if signs, such as dulness, flatness, and bronchophony, persist and 
become more marked over the whole side of the chest. 

Meningitis may complicate the disease. Care should be taken not 
to confound cerebral symptoms with true meningitis. 

Pericarditis complicating bronchopneumonia is apt to be puru- 
lent, and is rarely diagnosed during life. I have seen cases in 
which during life repeated examinations failed to reveal positive 
signs of efl'usion into the pericardium, but in which purulent peri- 
carditis was found at autopsy. This is frequently true of cases in 
which the eff'usion is limited (30-50 grammes). If bronchopneu- 
monia occurs in the left lung with consolidation anteriorly and some 
pleural eflusion, it is almost impossible to diagnose moderate peri- 
cardial efliision. The complication is very fatal. 

Pflsterer has recently published a number of cases of pneumo- 
coccus osteomyelitis and metastases occurring by way of the blood 
or lymph-stream. In some cases the arthritis may precede the pneu- 
monia ; in others, may follow it. The portals of infection include 
the tonsil, among others the mouth or nose, the ear or peritoneum. 
Traumatism may be a predisposing factor. Netter found 3 of ar- 
thritis in 1218 cases of pneumonia. It is therefore rare as com- 
pared to other complications of pneumonia, such as otitis or menin- 
gitis. I have seen one case in a newborn infant, the subject of con- 
genital syphilis, with bronchopneumonia of a syphilitic character. 
In this case the hip-joint was the seat of pneumococcus suppuration. 
As a rule, the larger joints, the shoulder or knee, are affected. It is 
generally monarticular, but may be polyarticular. The symptoms in 
some cases escape observation ; in others, the symptoms are similar 
to those of osteomyelitis with arthritis. If the arthritis is very 
acute and other organs are involved, death may result ; but, on the 
other hand, if the joint is evacuated in time, recovery may take 
place. The pneumococcus arthritis involves the tissues surrounding 
the joints. The cartilages of the joint are rarely involved. Pneumo- 
coccus osteitis aflects the cortical layers of the bone in the vicinity 



BR ONCHOPNE UMONIA. 



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592 DISEASES OF THE RESPIRATORY SYSTEM. 

of the epiphyseal line. Large sequestra are rare. Of 41 cases, 15 
occurred in childhood in the first two years of life. 

The prognosis is good, according to some ; but of 44 cases of 
pneumococcus arthritis and osteitis collected by Pfisterer, 23 died. 
Death was due to complications, such as pneumonia, empyema, men- 
ingitis, endo- or pericarditis ; therefore the prognosis is good only in 
uncomplicated cases. 

Physical Signs. — Clinically the physical signs of bronchopneu- 
monia are divided in those of the following stages : the first stage — 
invasion, the second stage — consolidation, the third stage — resolution. 
There is no sharp line of demarcation between the signs of the stages. 

First Stage. — Inspection shows the face to be flushed on one or 
both sides, and the nostrils to be dilated ; with each inspiration 
there is drawing inward of the peripneumonic groove and sometimes 
of the suprasternal tissues over the upper part of the trachea. 

Palpation. — If bronchitis is present, there may be rhonchal 
fremitus, but it is frequently absent. 

Percussion.- — In the early stage, there is, just before consolida- 
tion, slight dulness over small areas, which in young infants with 
thin-walled chests may have a sliglitly tympanitic note (tympanitic 
dulness). Other parts of the chest may have a vesiculotympanitic 
note. 

Auscultation. — If bronchitis is present, the rales of bronchitis 
may be heard. The respiratory murmur is rude. By careful exami- 
nation of all parts of the chest one or more areas in which are heard 
fine crepitant rales may be found. They may easily be overlooked, 
and may disappear when the infant cries or coughs, and during the 
examination. 

Vocal resonance is slightly increased over areas in which there 
is slight dulness or the beginning of consolidation. The whole pos- 
terior aspect of the thorax from above downward, and also the axil- 
lary fossa, should be examined. The apex of the lung in front, and 
the lower part of the thorax in front and behind on both sides, 
should be carefully examined, as well as the areas of the borders of 
the lungs where they come in contact with the chest-wall. Increased 
vocal resonance and slight dulness alone, especially over the apex 
of the right lung in front and behind, should be accepted with great 
caution as indicative of the beginning of bronchopneumonia. 

Dyspnoea should not be looked upon as a sign of pneumonia. 
The crepitant rale in a circumscribed area or in several areas is 
the sign pathognomonic of this stage. 

Second Stage. — Inspection shows no condition differing from 
those of the first stage. 

Palpation. — If the area of consolidation is limited, there is no 
change, because the area and the chest are small. If there is effusion 
in the lower portion of the pleural cavity, the fremitus may be dimin- 



BRONCHOPNEUMONIA. 593 

ished over the lower part of the chest, although the pneumonia is in 
the upper part. Fremitus is therefore misleading, and is only con- 
firmatory in the presence of other signs. 

Percussion reveals dulness in complete consolidation or dulness 
with a tympanitic note in the beginning of consolidation, and also 
flatness if fluid is present over the consolidated area in the lower 
part of the lung. The dulness may involve a very small area or an 
entire lobe of the lung. There may be slight resistance to the per- 
cussing finger over the consolidated area. The unaffected lung is 
hyperresonant. 

Auscultation gives bronchophony and bronchial or broncho- 
vesicular breathing over the consolidated areas. These are not nec- 
essarily present over consolidated lung. In infants and children 
there may only be abnormally rude respiratory murmur and in- 
creased vocal resonance. Fine crepitant pleuritic rales may be 
heard over the consolidated area. 

Diagnostic stress is to be laid on complete dulness with bron- 
chophony and bronchial breathing. 

Third Stage. — Palpation will give increased fremitus if the 
area of lung consolidation is large and there is no fluid over the 
area. 

Percussion. — As in the first stage, there is dulness to a varying 
extent, with a tympanitic note showing the return of air into the 
lung. 

Auscultation gives a crepitant rale, as in lobar pneumonia. 
The voice and breathing are less bronchophonic. Dulness may 
persist for days or weeks. In some cases there is fluid, which 
increases the dulness or flatness. Dulness, crepitant rales, bron- 
chophony, and bronchial breathing are constant features, and are 
diagnostic. In infants and children, bronchophony is more con- 
stantly present than bronchial breathing. In the bronchopneu- 
monia of the newly born infant, it is sometimes possible to discover 
with the small bell of a stethoscope areas in which air does not 
enter (atelectatic). 

Equivocal Signs likely to be Mistaken for the Beginning of Broncho- 
pneumonia. — In infants and children, the physician is apt to be easily 
misled into a diagnosis of incipient bronchopneumonia. Equivocal 
signs — i. e., signs which are not absolutely diagnostic — are apt to be 
met in certain parts of the chest and in the presence of rational 
symptoms, such as fever or apparent dyspnoea, undue importance 
may be attached to them. These signs are as follows : 

a. A slightly high note on percussion and an increase of vocal 
resonance or fremitus, with a rude respiratory murmur on the right 
side over the apex in front or behind. It should not be forgotten 
that this region, especially in infants, normally shows varying degrees 
of these signs as compared with the left side. 
38 



594 mSEASES OF THE RESPIRATORY SYSTEM. 

h. A slight dulness over the lower part of the chest on the right 
side behind, due to the presence of the liver, is normal. To be 
abnormal, the dulness must be very marked and the vocal resonance 
much increased. The resistance to percussion must be pronounced 
in order, in the absence of more positive signs, to justify a sus- 
picion of the beginning of consolidation. 

c. Bronchial or bronchovesicular breathing too near the vertebral 
column behind on either side, between the scapulae, should be cau- 
tiously interpreted. In some infants, the breathing in this region 
is normally bronchovesicular. It is in this region that the diagnosis 
of central pneumonia is so often made — a diagnosis rarely verified 
by the subsequent course of a case. 

d. In some infants and children, especially from six to ten years 
of age, it is found that the fremitus and vocal resonance diminish 
behind from a short distance below the angle of the scapula to the 
base of the lung ; the breathing also is heard less distinctly. A 
diagnosis of incipient pneumonia or consolidation with fluid re- 
quires positive and unmistakable evidence very low down behind. 
The thick muscles of the back and organs behind the thorax, such 
as the kidney and liver, obscure slight signs below the ninth or 
tenth rib. Slight variations from the normal should not receive 
undue attention. 

Diagnosis. — Bronchopneumonia should be differentiated from 
the lobar fibrinous form of the disease. In children above five 
years of age this is not difficult ; in those under the second year, 
in whom fibrinous or lobar pneumonia is not uncommon, a posi- 
tive diagnosis of lobar pneumonia cannot be made until the stage 
of consolidation, and even at that time only as to distribution. In 
the main, it is made from the course of the temperature. In lobar 
pneumonia the temperature will fall by crisis after the usual period. 
A marked leucocytosis, which increases toward the day of crisis and 
then rapidly diminishes, is also a characteristic feature. There 
should be also the physical signs of lobar consolidation. 

If these symptoms and signs are all present, it may be assumed 
clinically that a lobar pneumonia is to be dealt with. Such a diag- 
nosis is always open to doubt, for a bronchopneumonia may have 
the lobar consolidation and the leucocytosis, but will rarely have the 
critical drop of temperature which occurs in lobar pneumonia. As 
to the onset, bronchopneumonia may set in with a chill, and lobar 
without one. The complications in both forms are identical ; 
empyema is as likely to occur in one as in the other. Lobar 
pneumonia is rarely prolonged in duration if complications are 
absent, while the bronchopneumonic type of disease is, as a rule, of 
longer duration and may be prolonged into a chronic course. 

Disseminated patches of consolidation in a lung in which there 
is general bronchitis point to bronchopneumonia ; diffuse bronchitis, 



BRONCHOPNEUMONIA. 595 

with fine crepitations in the lower lobes of both lungs, to broncho- 
pneumonia. The presence of a primary disease — measles, scarlet 
fever, typhoid fever, and influenza — will also influence the process 
in the lung. The secondary pneumonia is a bronchopneumonic 
process. 

Prognosis. — The mortality of bronchopneumonia, even under 
the favorable conditions of private practice, is as high as 25 per cent. 
In hospital practice it is much higher, and may reach 50 per cent, 
or more. It is increased in bottle-fed, rachitic, prematurely born, 
and syphilitic infants, and is greatest in the first year of life. The 
disease is especially fatal in newly-born infants, and in cases of 
gastro-intestinal disorder. The mortality rate increases in New 
York City in the months of December, January, and February, 
during which the weather is alternately moist, warm, and cold. 
Certain years show an increased mortality because of the severe 
nature of the epidemic. 

At the bedside, a prognosis is based on the condition of the lung, 
temperature, heart, and the presence or absence of nervous symptoms. 
A persistently high temperature, if there are areas of consolidation 
in both lungs, is of serious import. An abnormal pallor or slight 
cyanosis in a bottle-fed baby, even if well-nourished, is a danger 
signal. Forced and irregular action of the diaphragm is serious ; 
marked drawing inward of the sides of the chest, sometimes as high 
as the eighth rib, is a very unfavorable sign in infants. These cases 
show a depression of the suprasternal notch as marked as that 
which occurs in laryngeal obstru(;tion. Repeated convulsions and 
jaundice, with enlargement of the spleen, in rachitic infants indicate 
intense toxaemia. These cases are fatal. Marked tympanites at the 
end of the first week, in connection with diarrhoea and weakness of 
the heart, is an unfavorable symptom. Dyspnoea with respirations 
irregular in rhythm and depth denotes diffuse involvement of both 
lungs, and is present in the unfavorable cases. Cerebral symptoms 
supervening late in the disease are unfavorable. 

The favorable signs are a good muscular quality of the first sound 
of the heart, red lips and warm surface, good reaction after hydro- 
therapy, and periods of quiet sleep with full noiseless breathing, 
movements of the bowels normal or slightly green, and an absence 
of marked tympanites. Caution should be exercised in making any 
prognosis in a bronchopneumonia which shows a marked tendency 
to involve new areas of lung. 

In the treatment of bronchopneumonia of infants and chil- 
dren, it should be borne in mind that the disease is a self-lim- 
ited, acute, infectious one, and that there is no remedy which can 
abort it or prevent complications. As in lobar pneumonia, the 
ill effects of the disease must be counteracted as much as possible 
and the strength of the patient supported. Since the patients are 



596 DISEASES OF THE RESPIRATORY SYSTEM. 

of very tender age, remedies which are powerful in their ultimate 
effects are to be carefully avoided. The indications in the treatment 
are to counteract the effects of the temperature and to support the 
heart. 

The temperature in the most fatal forms of this disease in new- 
born infants is below the normal at times, and rarely reaches a very 
high point. In other cases of bronchopneumonia in older infants 
and children, it remains persistently above 103° F. (39.7° C). In 
these cases, as in lobar pneumonia, the various forms of hydrotherapy 
are utilized. Of all the methods, the cold compress applied to the 
chest, as before described, seems to be the most efficacious. Com- 
presses lower than 70° F. (21.1° C.) are not applied. The appli- 
cations may be renewed every hour, if the patient bears them well. 
It sometimes happens that a compress wrung out in water at 70° F. 
(21.1° C.) will depress the patient, causing cyanosis wthout reaction. 
In such cases, as in the lobar cases, I have found the warm bath, 
105°-107° (40.3°-41.6° C), of the greatest utility in relieving the 
nervous symptoms, such as restlessness and convulsive twitchings. 
Infants, as a rule, will not bear baths below 80° F. (26.6° C). I 
therefore do not utilize the cold full bath in bronchopneumonia in 
infants. I do not think it advisable to use the bath at 90° F. 
(32.2° C.) or higher, with cold douching of the head and shoulders, 
to obtain reaction in infants. The procedure rouses the patients only 
momentarily, and the subsequent depression is greater. Cold packs 
over the whole body are also heroic remedies, but are advocated by 
some authors. 

The heart is supported by means of digitalis, strychnine, camphor, 
musk, caffeine, and ammonium carbonate. Of these agents, the most 
useful are digitalis, strychnine, and musk. 

Digitalis is administered in the form of the tincture. A drop is 
given for every six months of the age of the patient. It should 
not be used unless the pulse is high, and should then be given 
every three hours. It is discontinued after being administered 
for two or three days. The effects of stronger preparations, such 
as the fluid extract, cannot be gauged so carefully as those of the 
tincture, and they are therefore less useful. The cases in which 
digitalis is of the greatest value are those in which there is cya- 
nosis to a mild degree, or excessive pallor denoting great cardiac 
weakness. 

Strophanthus may be administered alone or in combination with 
digitalis. The tincture is the form generally used. 

Strychnine is one of the most useful drugs in the treatment of the 
heart. An infant six months old w^ill bear grain ^-g-Q- or 2-^-g- (0.0003 
or 0.00025) very well. Older infants and children bear grain y^^- 
(0.0004) quite well. Strychnine should not be used in cases where 
there is excitability of the nervous system. 



BRONCHOPNEUMONIA, 697 

Atropine, which is so useful in adults, is not well borne by in- 
fants and children. 

Ammonium carbonate is one of the most useful drugs when for 
any reason digitalis cannot be used. Convulsions or restlessness 
are treated with the bromides of potassium and sodium, which may 
be combined. Chloral hydrate is combined with both, especially 
where one dose of bromide of potassium and chloral hydrate is 
given per rectum. 

I do not use poultices. Some authors use them as a routine 
measure. 

Inhalations of benzoin and turpentine are of little efficacy. 
They do not affect the local lesion in the lung, nor do they act on 
the mucous membrane as they do in catarrhal processes of the nose 
and throat. In some cases I have seen harm result from overload- 
ing the atmosphere with the odor of balsams. 

The patient should be isolated from the healthy children of 
the family and the room kept at a temperature of from 68° to 
70° F. (20° to 21.1° C.) and well ventilated. An open wood fire 
is 'the most satisfactory method of heating and ventilating the sick- 
room. 

In threatened oedema of the lungs I have found, as in lobar 
pneumonia, that the right ventricle is best relieved by nitro- 
glycerin, grain 2-^ to y^g- (0.0003 to 0.006) at a dose, and by the 
constant administration of oxygen containing 20 per cent, of nitrous 
oxide. 

Whiskey is so universally used that the mode of administering 
it should receive special mention. Alcohol should not be used as a 
routine remedy. In some of the milder cases its use is superfluous. 
There are other cases in which its use must be suspended because 
of the constant vomiting. In the severer types of bronchopneu- 
monia, in which the temperature is persistently high, the effects of 
the toxaemia may be counteracted by administering whiskey. In- 
fants receive from minims xx to xxx (1.2 to 2.0); older children 
a drachm (4.0) every three hours. The whiskey should be well 
diluted, and should be given after the nursings. 

The feeding of infants who take a substitute for the breast should 
be carefully watched, especially in bronchopneumonia, a disease in 
which diarrhoea is apt to supervene. If diarrhoea is present, the milk 
should be discontinued and a cathartic given. The infant is given 
a high rectal injection of warm normal saline solution twice daily, 
and is kept on solutions of egg-albumin and acorn cocoa until the 
intestinal symptoms subside. Milk is then again given. In these 
cases of intestinal disorder it is of the utmost importance to see 
that the milk is fresh and uncontaminated. 

The cases not couiplicated by diarrhoea are given a warm high 
rectal enema of the normal saline solution once daily. In infants, 



598 DISEASES OF THE liESPIRATORY SYSTEM. 

this procedure will ward off tympanitic distention of the abdomen 
and stimulate the heart. 

The cough is sometimes very harassing, and then only should be 
relieved. The camphorated tincture of opium or the wine may be 
given in moderate doses. Codeine is useful in older children ; 
morphine should not be used. In the many hundreds of cases 
which I have treated I have not found it necessary to use it. Strap- 
ping the chest to relieve pain is harmful in infants and children. 
The chest in these subjects is resilient, and any limitation of its 
motion reacts unfavorably in preventing a full expansion of the 
unaffected lung. 

Persistent Bronchopneumonia. 

{Chronic Bronchopneumonia.) 

Persistent bronchopneumonia is a distinct type of bronchopneu- 
monia the course of which extends over weeks or months, the patient 
meanwhile becoming much reduced in flesh and strength. These 
cases occur in weakly infants, usually in those who are bottle-fed. 
A distinct type of the disease complicates chronic enteric catarrh. 
Cases of this class belong in the category of Gastro-Intestinal Sepsis 
of Fischl, Escherich, and Czerny. Cases of another set complicate 
and follow pertussis, measles, and influenza. Lastly, there is a true 
tuberculous form which is not strictly included in the above classi- 
fication. The condition is thus rarely primary. 

Symptoms. — The infant or child has at first the symptoms of an 
ordinary bronchopneumonia. The fever, however, is of longer 
duration than in cases which recover. Cases of gastro-enteric affec- 
tion or pertussis will continue to have a remittently high tempera- 
ture, which may reach 105° (40.5° C), but fall to 101° or 100° 
(38.3° or 37.7° C.) on the same day. It will remain normal for 
days, and then rise again, as indicated in the chart (Fig. 118). 
There are cough, slight dyspnoea, emaciation, and gastro-intestinal 
disturbances. In cases of enteric catarrh the intestinal disease 
takes clinically a secondary place. Some of these cases eventually 
recover in spite of the progressive emaciation and high fever. 
This is especially the case in persistent bronchopneumonia which 
complicates pertussis. 

The Blood in Persistent Bronchopneumonia with Recurrent Invasions. 
— In the case from which the chart was taken there was a distinct 
increase of the number of leucocytes with each new rise of tempera- 
ture and fresh invasion of the lung. The number of leucocytes 
mounted as high as 80,000 to the cubic millimetre. A differential 
count showed that the polynuclear neutrophiles ranged at different 
times from 73 to 82 per cent, of the leucocytes and the small 



PEBSISTENT BE ONCHOPNE UM NIA . 



599 



lymphocytes (mononuclear) from 13 
to 21 per cent. As the disease pro- 
gressed, there were also signs of ex- 
treme anaemia, microcytes, megalo- 
cytes, and poikilocytes being present. 
Physical Signs. — On examination, 
there are found areas of consolidation 
of varying extent, generally made out 
posteriorly over the apex or toward 
the base of the lung. There are signs 
of general bronchitis, increase of fre- 
mitus, and dulness marked, slight, or 
combined with a tympanitic note. 
There may be fine crepitations here 
and there over the chest. If the 
areas are extensive, there may be 
bronchophony or bronchial breathing. 
The complete consolidation of prim- 
ary bronchopneumonia is not always 
present. The lung is only partially 
consolidated, so that the vocal reson- 
ance may simply be markedly in- 
creased or the breathing may be 
bronchovesicular. 

Diagnosis. — Persistent broncho- 
pneumonia may be suspected if there 
is an area of dulness at the apex of 
one lung which does not resolve after 
a lapse of weeks. In these cases, there 
are the other signs of partial or com- 
plete consolidation at the apices, the 
base of the lung continuing resonant 
in the absence of signs of pleurisy. 
The persistence of fremitus on the 
affected side, especially in the mid- 
region of the chest behind, will aid in 
excluding the presence of fluid. The 
rest of the lung is in these cases res- 
onant or hyperresonant. In doubtful 
cases the exploring-needle should be 
introduced into the chest to ascertain 
whether fluid is present. 

The treatment is practically an 
extension of the treatment of the 
primary condition. If there is an 
affection of the gastro-enteric tract. 






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600 DISEASES OF THE RESPIRATORY SYSTEM. 

it is treated. If there is pertussis, treatment proceeds on the lines 
usually followed in that affection. In some cases the administration 
of iodide of potassium in small doses has seemed to have a bene- 
ficial effect on the course of the process in the lung. 

VI. DISEASES OF THE PLEURA 

Pleurisy. 

{Pleuritis.) 

Pleurisy in infancy usually occurs as a secondary disease ; it is 
rarely primary. 

Dry pleurisy is the form in which the pleura is inflamed without 
any appreciable formation of exudate in the pleural cavity. 

Pleurisy with effusion, or subacute pleurisy, as it is incorrectly 
called, is the form in which a serous or serofibrinous effusion is found 
in the pleural cavity. The form in which the effusion is of a sero- 
purulent or markedly purulent character is also called empyema. 

Empyema is therefore a purulent or suppurative pleurisy. There 
are other forms of pleurisy which occur with neoplasms of the lung 
or pleurae. These are not discussed in this section. 

Dry Pleurisy. 

Frequency. — Dry pleurisy, pure and simple, is, in my experience, 
clinically not common among infants and young children. As an 
independent affection, it is found more frequently after the fifth year 
of life. Clinically, the cause of this infrequency in infancy cannot 
be easily explained. Young infants and children rarely indicate 
the pain which is the leading symptom. The disease is masked by 
other symptoms occurring at the same time. Older children locate 
the pain and direct attention to it. 

Etiology. — This form may be primary or secondary. As a 
primary affection it is found in rheumatic subjects, especially those 
who are or have been subjects of disorders such as endocarditis or 
fibrinous adhesive pericarditis. In these cases the etiology is the 
same as that of rheumatism. The condition is secondary to pneumo- 
nia. It may be found complicating any of the infectious diseases — 
influenza, scarlet fever, measles, typhoid fever, or tuberculosis. In 
such cases the bacterial factor in the etiology is much the same as in 
the forms which will be considered under Pleurisy with Effusion. 
Pleurisy may complicate nephritis of the subacute or chronic type. 
Traumatism will cause this form of pleurisy ; exposure to cold or 
wet will predispose to it. 

Symptoms. — The cases of simple dry pleurisy not proceeding to 
the formation of effusion in the pleura, which have come under my 
notice, gave few symptoms. 



PLEURISY WITH EFFUSION AND EMPYEMA. 601 

Pain. — The children in the majority of cases complained of dis- 
tinct localized pain on exertion or on breathing deeply. There is 
also some local pain on external pressure. I have seen marked pleu- 
risy of the dry form in which pain was absent. This is most likely to 
occur in pleurisies secondary to nephritis. In the primary type, the 
patients continue to walk about, but are pale and have an anxious 
expression of the face. There is sometimes a rise of a degree or 
more in temperature and the respirations are increased and super- 
ficial. Those forms described by Henoch as setting in with convul- 
sions, high fever, and vomiting, have not in my experience remained 
dry fibrinous pleurisy, but have proceeded to the formation of effus- 
ion in the chest. The duration of dry pleurisy is variable, and in the 
rheumatic forms may extend over a long period of time. 

The diagnosis is not difficult, and is made from the physical 
signs and the history. On examination, a localized area over which 
there are a large number of dry crepitant rales is found. The 
rales are heard so close under the ear that they are distinguishable 
from the crepitant rales of pneumonia. In some cases there is a 
dry rubbing sound — a pleuritic friction — over the area affected. In 
the cases without complications there are no other signs. There is 
little or no dulness and no change in the voice or breathing-sounds. 

The prognosis is very good. Tuberculous disease of the lung 
is not a causative agent in these cases in children so frequently as 
in the adult. The primary dry pleurisies, with proper care, sub- 
side and gradually disappear. 

The treatment of dry pleurisy is very simple. If the subjects 
are rheumatic, they are put on small doses of salicylate of sodium. 
The bowels are kept open with a saline cathartic, preferably Carls- 
bad salts. The patients are kept in bed. It is not advisable to 
strap the chest to relieve pain. The desired relief can be secured 
by some local application of iodine or a sinapism. Codeine is 
administered in moderate doses to relieve the cough and pain. 



Pleurisy with Effusion (Subacute Pleurisy) and Empyema. 

{Purulent or Suppurative Pleurisy.) 

Frequency. — This form of pleurisy is common in infancy and 
childhood. The largest number of cases occur before the fifth year 
(Simmonds). The succeeding five years show the next greatest 
frequency. Israel found 29 per cent, of 206 cases to be purulent. 
Mackey estimates the purulent cases at 40 per cent, of the whole num- 
ber in children, as against 5 per cent, in adults. Combining the 
statistics of Simmonds and Hofmokl of Vienna, this form is found 
to have greater frequency in the male sex. According to these authors, 
the left side is more often the seat of the disease. Simmonds found 



602 DISEASES OF THE RESPIRATORY SYSTEM. 

the disease to be bilateral in only 7 out of 175 cases. Of 170 
of my own cases of empyema, 3 were bilateral. Of these the 
majority occurred before the fifth year, and 25 per cent, before 
the age of two years. The youngest patient was two months of 
age. 

Etiology. — Primary pleurisy, whether suppurative or serous, 
is rare. The literature contains cases of acute effusion in the pleural 
cavity, in which there was apparently no exciting cause or primary 
lung affection. The etiology must in such cases remain in doubt. 
Infection may take place through so many avenues that it is difficult 
to point out the mode of entrance. 

Pleuritis, serous or purulent, is generally secondary in infancy 
and childhood. All forms of lobar or bronchopneumonia may give 
rise to pleurisy, most of the cases being traceable to this source. 
The infectious diseases — measles, scarlet fever, pertussis, typhus 
and typhoid fever, diphtheria, forms of tonsillitis, retropharyngeal 
and mediastinal abscess, may precede or directly cause an attack 
of pleurisy. Chronic intestinal sepsis may cause empyema. In 
the latter case a pneumonia generally precedes the pleurisy or is 
present at the same time. In sepsis of the newly-born infant, 
there may be a complicating empyema. Osteomyelitis of the septic 
streptococcus variety may be complicated by purulent pleurisy. 
Tuberculous disease of the lung, actinomycosis of the lung, abscess 
of the liver, abscess in the mediastinum and abscess in the abdom- 
inal cavity involving the viscera, may cause pleurisy. Appendicitis 
may after the formation of abscess cause pleuritis by extension of 
the process along the coils of gut to the diaphragm. Finally, rheu- 
matism may cause pleurisy of a serofibrinous nature. Exposure to 
cold and wet is undoubtedly a predisposing cause. In children, it 
is common to have a history of a fall or a blow occurring just prior 
to the attack of pleurisy. 

Morbid Anatomy. — Pleurisies which accompany acute pneumo- 
nia are the most frequent. In these, there may be a slight injection 
of the pulmonary pleura and a loss of the normal lustre. Here and 
there a few fibrinous threads or adhesions may be found coursing 
over the surface of the pleura or running from the costal to the pul- 
monary pleura (dry or fibrinous pleurisy (pleuritis sicca)). In other 
cases, there is a thickened condition of both pleural reflections, caused 
by the deposit of fibrin on the surface. Sometimes the amount of 
fluid is small, while the pleura is very much thickened. The pleura 
itself may be little altered ; underneath the fibrin, the lymph-spaces 
and blood-vessels may be dilated. In some cases there is also a serous 
or seropurulent exudate containing leucocytes, endothelial cells, and 
bacteria. The fluid may be clear or bloody, turbid or opaque, 
yellow or greenish, and thin or creamy in consistency. Large clots 



PLEURISY WITH EFFUSION AND EMPYEMA. 603 

of fibrin may be found floating in the exudate. Adhesions may 
form pseudo-encapsulations of exudate, binding down the lung and 
preventing its expansion. In children, however, the tuberculous 
pleurisies are most likely to cause extensive thickening of the 
pleura. In addition to the deposit of fibrin on the costal and pul- 
monary pleura, there is a real inflammatory thickening of the tissue 
of the pleura itself, with a deposit of tubercle tissue. Serous or 
purulent exudate is encapsulated by adhesions, while the lung is 
bound down by layers of inflammatory tissue. In the tuberculous form 
the changes are progressive. In the acute inflammatory forms, the 
exudates are absorbed and the fibrinous deposit is organized into new 
connective tissue. In time the pleura may be restored to the normal. 
Adhesions, however, form an important factor in acute pleurisy of 
children. The pleura may in some cases be permanently thickened 
by a new layer of connective tissue persisting throughout life. There 
are forms of pleurisy not tuberculous in which this thickened con- 
dition not only remains, but extends from the pulmonary pleura into 
the lung along the interlobular tissue of the lung itself. There are 
induration and destruction of lung tissue. This induration is seen 
in connection with persistent bronchopneumonia. The amount of 
eifusion (purulent) is sometimes quite large in children, and may 
reach 1000 to 5000 cubic centimetres (Simmonds, Hofmokle). In 
scurvy and morbus Werlhofii, blood may be effiised into the pleural 
exudate. 

Bacteriology. — Pleurisy or empyema is divided into several 
groups according to the class of bacteria found in the exudate. It 
is Avell established that the bacteria are the essential cause of the 
disease. 

The first and largest group is that in which the pneumococcus of 
Frankel, the lanceolate diplococcus, is found. These cases are called 
metapneumonic. They may occur during the progress of a pneumo- 
nia or after it has run its course. In some cases the process in the 
lung plays clinically a secondary role. The pneumococcus seems to 
occasion very little disturbance in the lung and to spend its force on 
the pleura. Thus within three days after the initial chill the pleura 
is filled with serous or seropurulent fluid. Netter found that of 28 
pleurisies in infants and children 53 per cent, were due to the 
pneumococcus. In 212 cases of empyema I found the pneumococcus 
by culture in 75 per cent. 

The second group comprises those cases in which the streptococcus 
alone, the stapylococcus, or the streptococcus with the pneumo- 
coccus or staphylococcus, is found. Netter found that 17 per cent, 
of his cases were of the streptococcus class ; 1 per cent, of my cases 
were due to this micro-organism. In cases of the septic type, such 
as complicate sepsis of the newborn or osteomyelitis, or follow 
scarlet fever, the Streptococcus longus is found in the exudate. 



604 



DISEASES OF THE RESPIRATORY SYSTEM. 



These cases are severe. Six per cent, of my cases were caused by 
the staphylococcus. In 9 per cent, of my cases of empyema the 
streptococcus and pneumococcus were both found in the exudate. 
Although the pleurisies in which the streptococcus and staphylococcus 



Fig. 119. 



Fig. 120. 



\'^ 





Fig. 121. 



Fig. 122. 




Fig. 119.— Streptococci from the pus of empyema ; pure culture. Photomicrograph. X 1000. 
Figs. 120 and 121.— Pneumococci (Diplococcus lanceolatus) from the pus of empyema. Cover- 
glass preparations showing capsule. Pliotoniicrograph. X 1000. 
Fig. 122.— Pneumococci (Diplococcus lanceolatus) ; pure culture from the pus of empyema. 
Photomicrograph. X ooO. 



are found may follow a pneumonia, they may also be secondary to 
a follicular amygdalitis, the exanthemata, typhoid fever, influenza, 
diphtheria, sepsis^ and osteomyelitis. 



PLEURISY WITH EFFUSION AND EMPYEMA. 605 

The third group of cases comprises those in which either the, 
tubercle bacillus is found in the exudate, or the exudate is free from 
micro-organisms. The latter condition is frequently presumptive 
evidence of a tuberculous infection (Ehrlich). The tubercle bacillus 
was found in 1 per cent, of my cases, while in 3 cases the findings 
both by cover-glass spread and culture were negative. This would 
at most give a frequency of 2 per cent, for the tuberculous variety 
of pleurisy or empyema. 

The last group is that in which micro-organisms other than those 
mentioned are found in the pleuritic exudate. Such cases have been 
observed in connection with typhoid fever in which the Eberth 
bacillus has been found. Escherich has found the coli bacillus in a 
case of empyema. I have seen one case of this kind. The bacillus 
of the saprophytic variety and that which causes a putrid empyema 
are found in cases of this fourth class. 

The following table shows the relative frequency of the various 
forms of pleurisy and empyema with the varieties of bacteria in the 
exudate : 

Children. Adults. 

Netter Koplik 

28 cases. 212 cases. 
Pneumococcus 53.6 per cent. 75 per cent. 17 per cent. 

Pneumococcus and Streptococcus 3.6 " 9 " 2.5 " 

Streptococcus 17.6 " 10 " 53 " 

Staphylococcus 6 " 1.2 " 

Putrid 10.7 " 

Tubercule bacillus 14.3 " 2-3 " 25 " 

The most important fact to be deduced from the statistics is that 
while tuberculous pleurisy in children has a frequency of 2 to 3 per 
cent., adults show a much greater frequency, many of the strepto- 
coccus cases being tuberculous in the latter subjects. This figure 
added to the number of cases in which tubercle bacilli are found 
in the exudate would bring the frequency in the adult to at least 
the 45 per cent, given by Bowditch as the relative figure. 

The physical characteristics of an effusion in the chest are of 
clinical importance. An effusion if purulent has usually the gross 
physical characteristics of ordinary pus. In some cases the effusion 
is at first clear and serous, but is subsequently seen to be purulent 
without the occurrence of any extraneous infection. In other cases 
the effusion may be a cloudy serum, which on exploratory punct- 
ure is after a few days found to be purulent. In rare cases the 
effusion or exudate in the pleura is hemorrhagic. An effusion of 
that character has not the same significance in children as in adults. 
In the latter such effusions may be tuberculous or due to some morbid 
growth of the pleura ; this is not necessarily the case in children. 
I have had a number of cases of hemorrhagic effusion into the 
pleural cavity. In none of them was there a tuberculous element. 



606 



DISEASES OF THE BESPIRATORY SYSTEM. 



In all, streptococci were found in the effusion, and in some the 
admixture of blood could be traced to a scorbutic tendency. In 
one case, in an adolescent with localized effusion of a hemorrhagic 
nature, there was an actinomycosis of the pleura and lung. The 
history of this case was not that of an effusion of an acute, but of a 
subacute chronic nature. 

Symptoms. — There are no symptoms characteristic or pathog- 
nomic of effusion in the pleura or empyema. The condition is in 
most cases masked by the symptoms of the causal affection. Cases 
following a pneumonia set in with a chill or a rapid rise of tem- 
perature, with which there may be a convulsion followed by stupor 
or cerebral symptoms. After this onset the fever continues, rang- 
ing from 103° to 105° F. (39.4° to 40.5° C), the pulse being 140 
to 180. There will be cough, great dyspnoea, and pain in the chest, 
which is especially manifest when the infant or child coughs. The 
breathing is shallow. After a few days the acute symptoms sub- 
side, the fever becoming remittent. The temperature may be nearly 
normal. The dyspnoea continues, although the temperature and 
pulse may be normal during part of the day. 

Fig. 123. 



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Lobar pneumonia ; fall of temperature, by lysis ; gradual rise after the thirteenth day, due 
to empyema. Operation on the nineteenth day. Recovery. Boy, four years of age. 

In some of the cases the effusion becomes apparent on the 
eighth day ; in others a purulent effusion is found in the chest on 
the twelfth or fourteenth day of the disease. The effusion, which 
finally becomes apparent in the chest, has been coincident in its 
onset with a pneumonia — there has been a pleuropneumonia. The 
process in the lung, however, takes a secondary place in the clinical 
picture when the effusion in the pleural cavity has accumulated. 

There is another set of cases in which the course of the disease 
is insidious. The patient may at the onset have had for two or 
three days a febrile movement which has subsided, leaving the child 
not quite well and with a slight febrile movement toward evening, 
a slight hacking cough, and some little pain in the chest on exertion. 
Langour and loss of strength are progressive. There may be ex- 



PLEURISY WITH EFFUSION AND EMPYEMA. 



607 



Fig. 124. 



haustiiig sweats at night. Examination of the chest will reveal an 
effusion. 

The metapneumonic pleurisies in infants and children have a 
characteristic course. The patient has a typical pneumonia. The 
temperature on the ninth, tenth, or thirteenth day may drop to the 
normal or subnormal, the respirations continuing high. A gradual 
rise of temperature follows, with physical signs of fluid in the chest 
(see Fig. 123). The pulse and respirations rise with the temperature. 
Toward evening there may at times be chilly sensations. Explora- 
tion may discover fully developed effusion in the chest, serous or 
purulent according to the severity of the pleuritic infection. As a 
rule the younger the subject, the more likely is the effusion to be of 
a purulent nature. The duration of the effusion in the chest will 
also be a guide in determining its nature. An effusion occurring 
after pneumonia in a young infant and persisting for a week after 
the pneumonia has run its course, is likely to be purulent. 

Diagnosis. — There are some symptoms, such as continued 
dyspnoea, a slight or troublesome cough, exhausting sweats, and a 
distinctly intermittent range of temperature, which in all cases of 
pleurisy should direct attention to the chest. None of these symp- 
toms is, however, pathognomonic of pleurisy, serous or purulent, 
since they may be found in other pul- 
monary conditions. The diagnosis of 
pleurisy with effusion or empyema should 
take into consideration not only the 
rational symptoms, but also the physical 
signs. 

The physical signs of pleurisy with 
effusion and of empyema are identical. 

Fluid in the Chest. — A. The 
chest partly filled with fluid. B. The 
chest full of fluid. 

A. The Chest Partly Filled with 
Fluid. — It is assumed that the greater 
part of the fluid is in the lower portion 
of the chest (Fig. 124). In children 
and infants it does not cause displace- 
ment of the viscera. 

Inspection may show fulness of the 
lower part of the affected side ; the 
lower part of the chest moves less than 
the normal side. 

Palpation. — Vocal fremitus will be felt over the upper portion 
of the chest in front or behind, and will be lost over the lower 
portion. 

Percussion of the chest in front will often give an exaggerated 




Pleural cavity partly filled with 
fluid. 



608 DISEASES OF THE RESPIRATORY SYSTEM. 

byperresonant tone over the upper lobe of tbe lung. Behind, there 
is almost always dulness to a greater or less degree above over the 
scapula, due either to thickening of the pleura or to an exceedingly 
thin layer of fluid. This dulness can be distinguished from dulness 
due to other causes by firm percussion which will elicit the pulmo- 
nary note of the underlying lung. Below, over the fluid, the 
dulness changes to complete flatness. 

Auscultation. — The voice and breathing may be heard over the 
whole side with as much intensity as on the healthy side, or with 
diminished intensity below the level of the fluid. Rales, generally 
pleuritic crepitations, may be heard above the level of the fluid. 
Bronchial breathing and voice may be heard over the fluid or at the 
level of the fluid, but this sign is not absolute. 

Diagnosis to justify needle exploration must be based on absence 
of vocal fremitus over the fluid and its presence above the fluid, 
dulness behind above the fluid, which on firm percussion gives a faint 
pulmonary tone and flatness over the fluid with slightly increased 
resistance to the percussing finger. 

Note. — The method of examining infants for fluid is invariably 
that indicated in the earlier part of the book. It is a mistake to 
examine the infant as it lies in the lap of the mother, for in this 
position the fluid will gravitate behind. When the infant lies on the 
face, the fluid will again gravitate to the anterior part of the chest 
and thus not be made out. In the earlier stages of pleurisy the fluid 
only partly fills the thorax. On account of the small size of the 
thorax in infants, it is impossible to determine the change of level 
of the fluid by changing the position of the patient. 

The resonant note over the lung apex in front should, in the pres- 
ence of dulness behind and flatness below, always arouse suspicion of 
fluid, for in these cases the lung seems to be compressed upward, 
forward, and inward, thus causing the vesiculotympanitic note in 
front and above. 

The chest is partly filled with fluid, as is shown in Figs. 125 and 
126. I have quite frequently found this condition in infants and 
children who have for a long time lain on the back, and in whom 
adhesions seem to have kept a layer of fluid in the position shown 
in the figure. It will be assumed for illustration that the right side 
is affected : 

On irispection, fulness of the intercostal spaces on that side 
may be detected ; the movement of the thorax is labored, and the 
intercostal spaces may be drawn inw^ard on inspiration. 

Palpation. — Vocal fremitus due to the lung's being in contact with 
the chest- wall may be present over the anterior aspect of the chest. 
Posteriorly, the fremitus will be entirely absent. 

Percussion. — Anteriorly, the note may be vesiculotympanitic ; 
posteriorly, there is complete dulness over the whole chest, which is 



PLEURISY WITH EFFUSION AND EMPYEMA. 



609 



more marked below. There is rarely the flatness obtained when the 
chest is full or half full of fluid. There is also resistance to the 
percussing finger. 

By perGussing firmly the note of the lung beneath will invariably 
be elicited ; breathing-sounds and voice-sounds will be heard as 
normal or distant. 

Fleuritic crepitations may be heard over the whole affected side ; 
there is no displacement of the liver or heart on the left side. 

Diagnosis of fluid before exploratory jjuncture must rest on the 
complete or partial absence of fremitus behind, and complete dulness 



Fig. 125. 



Fjg. 126. 





Fluid in a thin layer posteriorly in the pleura. 



or flatness. The quantity of fluid is small ; there is less resistance 
to percussion than when it is large. 

(B.) The Chest Full of Fluid {Bight Side). — On inspection, the 
objective signs of intense or moderate dyspnoea are found : The 
chest on the affected side is immobile ; the intercostal spaces are re- 
tracted with each inspiration ; the affected side bulges visibly. 

Falpation. — Vocal fremitus is lost over the whole side in front 
and behind. In rare cases a little fremitus is felt. 

Percussion. — Ordinary and firm percussion give a flat note over 
the whole chest in front and behind ; the resistance to the percussing 
finger is wooden. In front, flatness may be present over the 
apex of the lung (Fig. 127). In some cases in children a 
sound over the apex of the lung, which resembles the cracked- 

39 



610 



DISEASES OF THE RESPIRATORY SYSTEM. 



pot sound over cavities in adults, may be obtained. It may be due 
to lung compression. In other cases the resonance in front, over 
the lung of the affected side is vesiculotympanitic, owing to the 
pushing upward and forward of the lung and to its distention. 

Displacement of the Pleural Fold underneath the Sternum. — A 
very important aid in the diagnosis of fluid in either side of the 



Fig. 127. 



Fig. 128. 





Pleural cavity full of fluid. Flatness 
anteriorly and posteriorly. 



Pleural cavity filled with fluid. Lung 
displaced upward and forward. Resonance 
anteriorly over the apex, either vesiculo- 
tympanitic or of the cracked-pot quality. 



chest is the displacement of the line of the reflection of the pleura 
in front. Normally the pleurae of both sides meet underneath the 
sternum in the median line. Above, at about the level of the second 
rib, they depart gradually from each other. If there is a large amount 
of fluid in the right chest, the pleural fold of that side becomes 
distended and displaced to the left, and may be marked out above 
the heart by dulness to the left of the midsternum. If the left 
chest is full of fluid, the left pleural fold is displaced to the right 
and there is distinct dulness or flatness above, to the right of the 
midsternum (Fig. 129). 

Auscultation. — Auscultatory signs in infants and children are 
most puzzling when the chest is full of fluid, and little diagnostic 
value can be attached to them in some cases. The chest may be 
full of fluid while the breathing and the voice may be heard as on 



PLEURISY WITH EFFUSION AND EMPYEMA. 



611 



the unaffected side, and pleuritic crepitant rales or crepitations may 
be heard over the whole chest behind. In other cases, the breathing 
may be indistinct and distant, and in the lower part of the chest 
lost entirely. The voice may be bronchophonic in certain localities ; 
it may be of this quality over the whole diseased side of the chest 
behind, or the tubular sound may be conducted to the healthy side. 
The voice may be normal above and heard faintly below, toward the 
base of the lung. 

Diagnosis before exploratory puncture rests mainly on (a) com- 
plete absence of fremitus ; (6) absolute flatness on percussion with 



Fig. 129. 





\ ^ ^ It 






(p 


•': 






\\-^ 


1 




/ 






\ 


1 






\ 




/ s 




/ , ,- "' 




l. ■ 




' 




4 




^ 




V ' ^^ 








~~ — .„ '■ ■. __ 







Displacement of the left pleural fold in effusion (empyema) into the left pleural cavity ; 
flatness to the right of the midsternum as indicated. 



resistance to percussion ; (c) bronchial voice and breathing over the 
whole chest behind ; id) hyperresonance over the apex, and displace- 
ment of viscera, and of the pleural fold in front. 

Displacement of Viscera. — Liver. — In infants and young 
children the presence of fluid may be indicated by displacement of 
the liver downward on the right side. I have been able to verify the 
displacement in cases in which large amounts of fluid were present. 
In infants, the liver is so large and the projection below the border of 



612 DISEASES OF THE RESPIRATORY SYSTEM. 

the ribs so undetermined, that it is difficult to estimate the exact amount 
of displacement. The chest is so easily dilated that an ordinary 
amount of fluid accommodates itself without markedly displacing 
so heavy an organ as the liver. In children I have been able to 
make out a displacement of the liver downward before the evacua- 
tion of large quantities of fluid. Displacement is of confirmatory 
value in diagnosis. 

Heart — The heart-apex may be displaced toward the median 
line by fluid in the left pleural cavity. In older children also 
when the amount of fluid is large the apex is displaced and lies 
beneath the lower part of the sternum. A small amount of fluid 
will not always cause displacement, but will find its way around the 
heart. 

Remarks upon the Diagnosis of Fluid in the Chest, with Excep- 
tional Signs. — It is not always easy, even for the expert, to decide 
without puncture as to the presence or absence of fluid in the chest 
of infants and young children. The following signs will be of 
service at the bedside. 

Duration of Illness. — If an infant or child has been ill for 
two weeks or more with signs of pneumonia during the early part 
of the disease, the physician should be watchful in the presence 
of the following conditions : If the temperature does not fall, but 
though remitting still continues ; if the signs of consolidation of a 
small or large area give place to dulness or flatness over a whole 
side behind, with bronchophony over the whole side — for if the con- 
dition of the infant is tolerably good, it is evident that such bron- 
chophony may not be due to the total consolidation of the whole 
lung ; if there is displacement of viscera, chiefly of the liver or the 
heart ; if there is drawing inward of the intercostal spaces during 
inspiration, with real immobility and bulging of a side and dulness 
or flatness and loss of fremitus. 

Fluid is very rarely encapsulated in a small area behind, about 
the midregion of the chest. Such areas are usually areas of per- 
sistent bronchopneumonia. In most cases, there is localized dul- 
ness, above and below which there is vesiculotympanic resonance, 
normal pulmonary resonance or exaggerated resonance. There is 
distinct respiratory movement of the affected side. On the other 
hand, a collection of fluid between the lobes of the lungs (inter- 
lobar) may give a localized flatness and all the auscultatory signs, 
such as bronchial voice and breathing, of a local collection of 
fluid. 

There are certain localities in which the diagnosis of fluid must 
be made with reserve : 

a. In a case on which I operated, fluid was found posteriorly 
over the situation of the upper lobe of the right lung. The fluid 
was completely shut off from the rest of the pleural cavity by a 



PLATE XVIII. 




Showing the correct position of the child and operator in 
making an exploratory puncture for fluid in the pleural 
cavity. The plate is not intended to illustrate the point of 
puncture, ^vhich is always at the discretion of the operator. 



PLEURISY WITH EFFUSION AND EMPYEMA. 613 

membrane stretching from the thoracic wall to the interlobar fissure 
of the lung. Post-mortem showed the case to be tuberculous, the 
lung on the affected side being the seat of persistent tuberculous 
bronchopneumonia. I have seen similar cases which were meta- 
pneumonic. 

6. Fluid over the upper lobe in front only, is rare. I have seen 
one case, but no operation or verification was permitted. 

c. Fluid over the lower lobe of the lung, in front on the right or 
left side without corresponding signs behind, is uncommon. 

d. Circumscribed collections of fluid behind over the middle 
region of the lung or toward or in the axillary line are exceedingly 
uncommon. 

e. In the chapter on the physical signs of pericarditis, it will 
be shown how a pleurisy or empyema on the left side may be mis- 
taken for pericarditic effusion. 

Physical signs having led the physician to suspect fluid, the 
chest should be explored for two distinct reasons : to determine abso- 
lutely the presence of fluid, and to ascertain whether it is serous or 
purulent. 

Diagnostic Exploratory Puncture of the Chest. — The instru- 
ments necessary are an exploring needle, a millimetre in calibre, 
and a large barreled aspirating syringe. The needle should not be 
too short, else it may snap off in the chest. The needle and 
syringe are boiled for a few moments before being used. The 
patient is held in the arms of the nurse or mother, so that the 
posterior aspect of the chest may be exposed. Older children may 
sit on a table. The chest is scrubbed with soap and water, washed 
off with ether, then with alcohol, and finally with a solution of 
sublimate (1 : 2000). The arms of the infant or child are firmly 
held and the chest steadied in such a manner that should the 
patient move suddenly the needle will not break in the chest 
(Plate XVIII.). 

Introduction of the Needle. — The chest is again percussed 
and the needle introduced into the intercostal space in which per- 
cussion elicits the most marked dulness or flatness. This rule should 
be invariably followed ; the needle should not be introduced into 
any particular intercostal space. On the right side the physician 
should avoid putting in the needle too low down (liver) ; on the left 
side he should avoid introducing it too deeply for fear of wounding 
a large vessel at the root of the lung. The needle should not be 
entered too near the vertebral column. The needle having been 
introduced one or two centimetres, the piston is drawn and held thus 
a few seconds. Sometimes the fluid is thick and does not flow freely 
into the syringe. The syringe should not be introduced and then 
withdrawn and pointed up and down in various directions in quest 
of fluid, for fear that the struggles of the patient, even if he is firmly 



614 DISEASES OF THE RESPIRATORY SYSTEM. 

held, will cause puncture of the luug and bloodvessels. The 
needle should be withdrawn as rapidly as it was introduced and the 
whole operation completed in less than a minute. The external 
wound is covered with a small strip of iodoform gauze held in 
place with rubber plaster. The needle while in the chest should 
be held loosely. If it is held firmly, any sudden movement of 
the patient will cause it to break off in the chest. The needle 
should not be introduced too deeply for fear that it may enter a 
dilated bronchus and withdraw purulent secretion which may be 
mistaken for empyema, or that it may wound the lung and cause 
hemorrhage or pneumothorax. 

Perforating Empyema. 

An empyema may perforate externally. In that case there will 
be an extensive infiltration of the tissues external to the ribs on the 
affected side, resembling a large phlegmon, and the signs of fluid will 
persist. If the perforation occurs on the left side, the movements 
of the heart are likely to be conducted to the external swelling, and 
there is then what has been called pulsating empyema. The em- 
pyema may perforate through the lung, and the signs will then vary 
with the length of time during which the perforation has existed. 
It is customary for writers to repeat one another in recounting the 
physical signs of pneumothorax in a chest in which fluid (pleurisy 
or empyema) is present. In infants or very young children the 
following classical signs of pyopneumothorax observed in adults are 
not commonly found : amphoric breathing, amphoric voice, metal- 
lic tinkle, and succussion-sounds. My cases were in children under 
two years of age. The perforation in the lung must have been too 
small or too valvular to permit of the entrance of much air into the 
pleural cavity. These cases at first showed all the signs of the con- 
dition which was proved, on introducing the needle, to be empyema. 
Operation being refused, after a few weeks (three months after the 
beginning of the disease), the signs changed as follows : 

Periodic expectoration of large quantities of pus following 
coughing spells. 

Fremitus diminished over the whole right side and almost lost 
below. 

Dulness over the whole side in front and behind, with tympani- 
tic note on deep percussion only. Voice normal ; breathing 
normal — at least not varying from that on the healthy side. In 
the intervals of expectoration, there were in some cases bronchial 
voice and breathing. 

No succussion-sounds, no tinkling, no amphoric signs. The 
classical signs seen in adults are met in children above five years 
of age. 



PLEURISY WITH EFFUSION AND EMPYEMA. 



615 



Course and Termination. — Pleurisy with effusion and empyema 
have been considered together, because, in infants and children under 
two years of age, the effusion in the chest may at first be serous, but 
subsequently change into purulent exudate. A serous effusion may 
be followed by a purulent one ; it may remain serous and be absorbed 
as such. Thus it is best, especially in infants, to introduce an 
exploring-needle into the chest to determine the nature of the fluid 
as soon as its presence is suspected. In older children also, this may 
be done at the outset. If a clear fluid is at first obtained and the 
symptoms do not retrograde within a short time, the needle should 
be again introduced to determine whether the fluid has remained 
serous. It is frequently found to be purulent although no infection 
has occurred as a result of the first puncture. With ordinary cleanli- 
ness, the possibility of infecting a serous effusion in the chest and 
thereby causing it to become purulent is very slight. Purulent 
effusion appearing after the first exploratory puncture has shown the 
effusion to be serous, may be due to two causes : either to continu- 
ance of the pleuritic inflammation, or to the fact that if the infant 
or child has lain quietly in bed the purulent elements of the effusion 
have gravitated to the lower portion of the chest, leaving a clear 
serum above at the level of the puncture. 

Fig. 130. 




B 



m 



Empyema, left pleura, followed thirteen days after operation by bronchopneumonia at the 
apex of the right lung. Male child, twenty months of age. Recovery. 



The prognosis of pleurisy with effusion and of empyema in in- 
fants and children is good. If treated in the proper manner, it is not 
more serious than the original causal affection. In private practice, 
the patient being under constant supervision of the physician, the 
outlook is very good. An effusion can be discovered early and the 
patient relieved. In hospital practice the results are still good if 



616 DISEASES OF THE RESPIRATORY SYSTEM. 

the cases are simple aud come under treatment before systemic in- 
fection has taken place. In my service of 120 cases of all kinds, 
there were 20 deaths, 4 of which occurred from one to five days 
after operation. Sepsis had been present before operation and caused 
the fatal issue. The septic cases therefore give an unfavorable prog- 
nosis, as do also those of a tuberculous nature. In the latter, as in 
other forms of tuberculosis in children, the outlook is better than in 
the adult and recoveries are not infrequent. 

Of the 20 cases of death after operation for empyema, broncho- 
pneumonia either persistent or recurrent caused the fatal issue in 11, 
general sepsis in 2, marasmus and ulcer of the duodenum in 1, and 
cerebral embolism in 2. A complicating pericarditis of a suppurative 
nature may cause death. It is not always possible to diagnose this 
condition during life. The complication most to be feared in 
empyema is a bronchopneumonia involving either lung. In many 
cases the bronchopneumonia is present at the time of operation, or 
it may come on a week or two afterward during apparent conva- 
lescence. 

The prognosis of tuberculous empyema is not so unfavorable in 
children as in the adult. In the former, empyema of a tuberculous 
nature, like other forms of tuberculosis, may with skilful management 
make an apparent recovery, though with marked deformities of the 
chest-wall. In this form of empyema the pleura is thickened, bind- 
ing down the lung and thus preventing expansion. Extensive rib 
resections thus become necessary in order to close up the suppurating 
cavity left by the unexpanded lung. 

Treatment. — If on exploratory puncture a serous exudate which 
only partly fills the pleural cavity is found, the expectant plan is 
followed. The boAvels are kept open with an enema or a saline 
cathartic is administered daily. For this purpose a saline enema, 
or in older children a teaspoonful of Carlsbad salts in warm water 
mixed with milk, is efficient. Local vesication is not needed nor is 
it advisable. The effusion is absorbed if the patients are kept 
quiet and the diet is easily assimilable. Citrate of potassium in 
grain v (0.3) doses every three hours may be given to older chil- 
dren. If the fluid increases in quantity, fills up the chest, causes 
dyspnoea or pressure symptoms, and is serous in character, the chest 
should be aspirated. The best form of aspirator for the practitioner 
is the Potain. The patient is aspirated in the sitting posture. The 
chest-wall having been cleansed, the needle is introduced in the 
posterior axillary line toward the lower third of the chest cavity. It 
is not withdrawn until the flow has ceased or the lung can be felt 
against the needle in the pleural cavity. As soon as this occurs the 
needle is withdrawn and the puncture opening covered with a piece 
of iodoformized gauze. It sometimes happens that there are signs 
that the chest is filled with fluid and yet very little flows into the 



PLEURISY WITH EFFUSION AND EMPYEMA. 617 

instrument. In such cases the needle should be withdrawn and 
introduced into the chest-wall at another point. The coughing attack 
which occurs during aspiration will subside on the patient^s taking 
the recumbent posture. If the chest is quite full of fluid, it is well 
not to empty it entirely. Sometimes alarming syncope with other 
signs of cardiac weakness, such as cyanosis, has supervened. If a 
limited quantity of fluid is removed, the absorption of the rest will 
follow rapidly. 

A daily saline cathartic is given ; the patient is kept quiet and 
allowed a nutritious and easily assimilable diet. The administra- 
tion of salicylate of sodium may hasten absorption, especially in 
cases in which there is a rheumatic history. If there is pain or a 
harassing cough, small doses of codeine should be given. 

Empyema. — When the presence of pus in the chest is once estab- 
lished, it is imperative that it be evacuated with the least possible 
delay. In infants and children it is not advisable to temporize by 
first performing aspiration. Retention of even a limited quantity 
of purulent exudate in the pleural cavity not only leads to emacia- 
tion and physical weakness as a result of continued fever, but general 
sepsis may also result. Aspiration is not efficient, and is to-day 
practically abandoned as a mode of treatment. The physician may 
either incise the intercostal space or resect a rib to obtain drainage. 

Simple incision in the intercostal space is eflicient in many cases 
of empyema occurring in the first eighteen months of life. In these 
frail patients, excision of the rib has been sometimes accompanied 
by discouraging results. 

The greatest number of deaths after any operative procedure for 
the relief of empyema occur in children under the age of eighteen 
months. The strength of the patient should be supported as much as 
possible. A general anaesthetic is not necessary for patients under this 
age. I find that bronchitis and pneumonia very frequently result from 
the general use of anaesthetics in young patients. Local anaesthesia 
is all that is needed. Ethyl chloride in tubes is very efficient. The 
surface of the chest is carefully cleansed with soap and water, alco- 
hol, ether, and sublimate. An incision two inches long or there- 
abouts is made obliquely in the tissues over the intercostal space. 
The space in which a needle has been previously introduced and 
pus found is chosen. The exploring-needle is always introduced 
just before operation. Frequently, although pus has been with- 
drawn from the chest, at a second aspiration none can be found. 
The theory is that either there was a small localized collection of 
pus at the first point of aspiration, or that the needle entered a 
bronchus and withdrew secretion collected there. 

On the right side the incision should not be too low, else a tube 
cannot be retained in the chest on account of the high position of 
the diaphragm. The seventh or the eighth space in the posterior 



618 



DISEASES OF THE RESPIRATORY SYSTEM. 



axillary line is the best location if pus is present at this point (Fig. 
131). On the left side, incisions should not be made too far for- 
ward, else the drainage-tube may impinge against the pericardium. 



Fig. 131. 




><>.<^' 







-^ .„ 



I 



■<. 



Empyema, site of incision in line with the angle of the scapula. 

The superficial tissues having been incised, the intercostal 
muscle is incised, the operator keeping as nearly as possible in the 
median line of the intercostal space and avoiding the lower border 
of the upper rib, yet not cutting too close to the lower rib. When 
the vicinity of the costal pleura is reached, a closed dressing-forceps 



PLEURISY WITH EFFUSION AND EMPYEMA. 



619 



is introduced into the pleural cavity and opened to widen the 
puncture. A small drainage-tube or two small tubes are placed in the 
pleural cavity and prevented from falling into the pleural space by 
safety-pins passed through them at the distal ends. The pus is not 
evacuated at the time of operation. The sudden evacuation of fluid 
which has been retained in the chest for a long time is apt to cause 
untoward syncopal symptoms. Gibson has made the excellent sug- 
gestion that as soon as the pleura is opened the drainage-tube should 

Fig. 132. 




Exsection of rib for empyema on tlu- right side. Shows the resulting deformity. Five weeks 
after operation. Child, four years of age. 



be quickly introduced into the chest, the gauze dressings applied, 
and the pus allowed to escape gradually into the dressings. The 
dressings consist of a pad of gauze around the tubes, covered by 
a dry sterilized gauze dressing which is renewed every day. The 
chest should not be irrigated. No instrument should be introduced 
into the chest cavity to loosen adhesions. The whole operation is 
extremely simple, and should not occupy more than a few minutes. 
Children under five years, and even older ones may be treated by this 
method. In the older subjects, however, the chest-wall is not so 
resilient ; there are adhesions, and if they are numerous and clots are 
abundant in the exudate a subsequent excision of the rib may be 



620 DISEASES OF THE RESPIRATORY SYSTEM. 

necessary. On the other hand, the main object of the practitioner 
in these cases is to evacuate the pus, and incision will accomplish 
this quite as well as the other operation. If subsequently more 
drainage is needed, the patient will be stronger and better able to 
stand the more serious procedure. 

Incision is therefore the practitioner's operation even in older 
children, with whom anaesthesia must, however, be used. Chloro- 
form is the safest and most easily taken ; very little need be 
used. As soon as the skin incision has been made, anaesthesia 
should be suspended. 

I perform excision of the rib in the cases of children above the age 
of eighteen months, unless there is a contraindication. Severe pneu- 
monia, high fever, cardiac weakness, acute pericarditis or endo- 
carditis, as complications, are contraindications. In such cases 
incision alone is performed. I excise the rib in the usual way, taking 
two or three centimetres of rib subperiosteally and incising in the 
midline of the posterior layer of periosteum to enter the pleural 
cavity. The finger is not inserted into the pleura to loosen adhe- 
sions. After the pleura is opened, double drainage-tubes are intro- 
duced by Gibson's method, as in the operation of simple incision. 

Sinus. — After incision or resection of the rib, a suppurating sinus 
may remain for months. If a probe introduced into a sinus of this 
kind impinges against callus or denuded bone, a so-called sec- 
ondary operation is necessary to take out the denuded rib or callus. 
This involves a difficult surgical procedure, which it is not necessary 
to describe here. A sinus of this form will not close until the bone 
is removed. Temporizing only subjects the patient to the dangers 
of prolonged suppuration (amyloid degeneration). 

Adhesions binding down the Lung. — There is another class of 
cases in which a large amount of fibrin has been thrown out on the 
visceral pulmonary pleura. The lung is thus cramped by an en- 
velope of thickened pleura and cannot expand. A large suppu- 
rating cavity or a suppurating sinus is left between the pulmonary 
and costal pleura. This cavity must be made to close. In such 
cases the patients are allowed to be up and about. They are taught 
to blow colored fluids from one bottle to another in the way de- 
scribed by James, of New York (Fig. 133). Two bottles of equal 
size, each half filled with the fluid, are used. In simple cases this 
method is very efficient ; in others it is of no avail. The operation 
of taking out two or more ribs with the intervening pleura must 
then be performed. In other cases a more extensive operation — 
the so-called Estlander, in which large pieces of several ribs are 
excised with the intervening costal pleura — is necessary. If the 
lung is firmly bound down by a coating of fibrin, the chest-wall 
must be opened by reflecting a flap of several ribs and the soft 
parts. The pleura is peeled ofi* the lung according to the method 



PLEURISY WITH EFFUSION AND EMPYEMA. 



621 



of Delorrae. The lung expands, the costal flap is sewn back in 
its place, and the chest sinus is in time closed as a natural con- 
sequence. 

The question of irrigating the pleural cavity in the treatment of 
empyema after operation has been much discussed. As a rule, if 
the temperature drops after operation and remains low, and the dis- 
charge is not fetid, no irrigation is indicated. If, however^ there 



Fig. 133. 




James' apparatus for expanding the lungs in empyema. 

are rises of temperature after operation, with a profuse or fetid dis- 
charge, the chest should be irrigated once daily with normal salt 
^solution. 

Bilateral Empyema. — The treatment of bilateral empyema will 
tax the judgment of the physician. One side, preferably the left 
in order to relieve the heart, is first operated on by incision or rib 
exsection ; the other side is aspirated, and again aspirated if the 
fluid or pus accumulates. After a week adhesions will have formed 
on the operated side, and the strength of the patient will warrant 
interference on the opposite side. When this is accomplished, the 
opening on the operated side must be closed by some device, such as 
a pad of gauze on which is placed rubber tissue covering, and the 
second side may be operated on by rib exsection or incision. 

I have followed this method in two cases without serious acci- 
dent. The interval of a few days between the operations is 
sufficient to allow adhesions to form on the operated side to such an 
extent that, when the second side is opened, the lung of the side first 
operated on does not collapse. If the sides arie operated on simulta- 
neously, the consequent partial collapse of both lungs causes marked 
symptoms of asphyxia. 



622 DISEASES OF THE RESPIRATORY SYSTEM. 

Hemorrhagic Pleurisy. 

Simple hemorrhagic pleurisy is not uncommon. It is seen in 
pleurisy following simple pneumonia, influenza, the exanthemata, 
and in infants or children in whom there is a tendency to scor- 
butus. Cases which appear to be rheumatic have been published 
(Starck). The hemorrhagic form of pleurisy with effusion may occur 
in very young infants (Lewin, eleven months) or in young children. I 
have met a number of cases in children who subsequently made a 
complete recovery, and in whom I could find no tuberculous ten- 
dencies. The prognosis in this form of pleurisy is therefore much 
better in children than in adults. In the latter, a hemorrhagic pleurisy 
is frequently indicative of a tuberculous factor in the etiology. 

Hemorrhagic Empyema. 

Hemorrhagic empyema is also not uncommon in infants and chil- 
dren. During the past year I have met four cases in which there was 
a hemorrhagic exudate. In one case the child was pale, though not 
emaciated. There may have been a scorbutic element. In another 
case, in a boy, no such etiology was indicated. In a third case, in a 
girl, the child was much reduced in health. In three cases the hemor- 
rhagic discharge persisted for days after the chest was opened and 
streptococci were found in the exudate. In one case the discharging 
pus was for weeks tinged with blood. In none of the cases were 
tubercle bacilli found in the pleuritic exudate. Three of the cases 
made a very good recovery. In these cases also I am inclined to 
believe that tuberculosis is not always an etiological factor. 



Subphrenic Abscess or Pyopneumothorax Subphrenicus. 

The positive diagnosis of subphrenic abscess should be made 
with reserve, because no pathognomonic symptom or physical sign 
of the disease is known. It is a very valuable fact that in 50 
per cent, of the cases thus far recorded, the abscesses have contained 
gas or air. The condition is rare (Maydl) in adults and more so 
in infants and children. The abscess is situated beneath the dia- 
phragm, and between that organ and the liver. It pushes the dia- 
phragm upward, and may thus encroach on the pleural space and simu- 
late a real pyopneumothorax. An area in the lower part of the 
thorax, which may give tympanitic resonance or tympanitic dulness 
from the second, third, or fourth rib downward, is thus caused. This 
resonance may even include the liver, which is displaced downward. 
Over the region of tympanitic resonance, especially posteriorly, the 
normal vesicular breathing is absent on expiration and present over 



SUBPHRENIC ABSCESS. 623 

the area on deep inspiration. It is a peculiarity of the condition 
that there may be amphoric breathing and metallic tinkle over the 
area, while anteriorly, just above it, from the second to the fourth 
rib, there is a sharp transition and normal breathing is heard. Behind, 
however, on deep inspiration, even over the region of tympanitic 
resonance, normal breathing may be heard over the lower part of the 
chest. Over the situation of the abscess the metallic tinkle and suc- 
cussion-sounds may also be heard. As has been stated, the liver 
may be displaced downward, crepitations are heard anteriorly over 
the liver (perihepatitis), or it may be impossible on account of intes- 
tinal conditions to make out the lower border of the liver. I have 
seen a subphrenic abscess on the left side displace the left lobe of the 
liver and the spleen downward. The heart is not displaced inward 
if the abscess is on the left side, but if displaced at all, is so in an 
upward direction. The lower thorax region may show no abnor- 
malities to inspection, while the upper abdominal region may be 
normal, painful to pressure, or slightly oedematous. 

Diagnosis and Treatment. — Exploratory puncture is resorted 
to in all of these cases. Diagnosis will be aided if the fluid obtained 
contains, in addition to pus, elements which denote the origin of 
the abscess, such as food particles, feces, histological debris or pig- 
ment from the liver. In many cases the liver suffers from the 
vicinity of the abscess. 

The treatment is surgical. 

References of Authorities for Collateral Reading. 

Bonnard-Favre : La temperature dans la pneumonie. Paris, 1898. 

Booker : Johns Hopkins Hospital Report, vi., 1896. 

Bowditch: Medical News, 1889. 

Cestan : La Therapentiqiie des Empyemes. Paris, 1898. 

Czerny and Moser : Jahrb. f. Kinderheilk., Bd. xxxviii. 

Finkler, D. : Die Acuten Lungen Entziindungen, etc., 1891. 

Fischl, R. : Volkmann's VortrJige, No. 220. 

Holt^ L. E. : ''Pneumonia in Young Children," Medical Eecord, 1885. 

Jurgensen : Croupose Pneumonie, 1883. 

Koplik : Etiol. Empyema, Arch. Ped., 1890; American Journal Medical 
Sciences, 1891 ; Arch. Ped., 1896. 

Netter: Soc. m^d. des Hopit., 1889-91. 

Neumann : Jahrb. f. Kinderheilk., Bd. xxx. 

Pott: "Pneumonie in Kindesalter," Bib. d. ges. med. Wissen., Bd. iii., 1898. 

Pratt, I. H. : "Histology of Acute Lobar Pneumonia," Johns Hopkins Hos- 
pital Report, vol. ix. 

Prudden and Northrup: "Studies in Pneumonia," etc., American Journal 
Medical Sciences, 1889. 

Spiegelberg, I. H. : "Lungen Entziindung u Magendarmkr.," Archiv f. Kinder- 
heilk., Bd. xxvii. 

Steffen, A. : Klinik der Kinderk., etc., to 1895. 

Stengel, A., and C. Y. White: "Blood in Infancy and Childhood," Arch, of 
Ped., April and May, 1901. 

Terrier and Reymond : Chirurgie du Coeur, Paris, 1898. 



SECTION VII. 

DISEASES OF THE CIECULATORY SYSTEM. 

I. DISEASES OF THE PERICARDIUM. 

Pericarditis. 

Pericarditis is an inflammation of the pericardium due to infec- 
tion, which may take place through the blood- or lymph-channels 
or may occur through contiguity to infected areas in neighboring 
structures. The existence of primary pericarditis or so-called idio- 
pathic pericarditis apart from rheumatism or infection is a matter of 
doubt. It is therefore to be regarded as secondary to other condi- 
tions or the result of direct systemic infection. 

Occurrence. — Pericarditis occurs in foetal life (Billard, Tardieu, 
Heiter) ; Bednar describes cases in newly born infants ; it is common 
in infancy and childhood. Steffen and Baginsky describe a number 
of cases occurring in infancy. Of 66 cases of pericarditis in chil- 
dren, Baginsky found 20 to occur during the first year of life. The 
next greatest frequency was between the first and the fifth year. 

Etiology. — The majority of cases occur as complications of acute 
articular rheumatism (Steffen, Friedreich, Bauer, Baginsky), with or 
without chorea. Tuberculosis and pleuropneumonia rank next as 
etiological factors. Pericarditis occurs in the exanthemata, scarlet 
fever, measles, and typhoid fever. It may complicate pertussis, 
diarrhoeal disorders, otitis, meningitis, peritonitis, mediastinitis, or 
any septic process, such as osteomyelitis. It is also in the newly 
born infant concomitant with septic conditions. Finally, trauma- 
tism may cause pericarditis. The tuberculous form is uncommon 
before the fifth year of life (S^e). 

Bacteriology. — The pyogenic bacteria most frequently found in 
pericardial effusions, and which play an etiological role, are the 
pyogenic streptococci and staphylococci, the pneumococcus of Frankel 
and Weichselbaum, the tubercle bacillus, the Friedlander bacillus, 
the Bacterium coli, and the Bacillus pyocyaneus (Ernst). 

Forms. — There are the same forms of pericarditis in children as 
in the adult subject. The forms with effusions have, however, a 
tendency to become purulent, especially in infants and younger chil- 
dren (Baginsky). In these patients, the fibrinous forms result in 
localized or general adhesions of the two layers of the pericardium 
40 ^25 



626 DISEASES OF THE CIRCULATORY SYSTEM. 

and in partial or complete obliteration of the pericardial sac (ad- 
herent pericardinm). 

Morbid Anatomy. — In the mildest forms, there is only a loss 
of lustre to the serosa in circumscribed or diffuse areas. The fluid 
in the pericardial sac may be increased in quantity and may contain 
cellular elements. In other forms, the surface of the pericardium is 
coated with a layer of fibrin of greater or less thickness. The fibrin 
may be in the form of bands or of small villous formations. There 
may be minute hemorrhages on the surfiice (Delafield). In more 
pronounced processes the fibrin is in the form of hemorrhagic tena- 
cious masses forming a thick network of strips or bands (cor 
villosum). The quantity of fluid in the sac varies. The fluid may 
contain blood. 

In the first stage of inflammation, the connective tissue of the 
pericardium is infiltrated with lymphoid cells and the vessels are 
filled with blood. After the third day, new vessels appear in the 
fibrinous exudate on the surface. Fibroblasts, spindle-shaped, 
spherical, and branching, form a network in this new tissue (Ziegler). 
Granulation tissue and finally new connective tissue replace the fibrin- 
ous exudate, after a period of weeks (productive pericarditis). The 
so-called opaque areas of thickened pericardium, the maculse tendinese 
seen in adults, are rare in children (Steffen). Adhesions, either 
localized or general, may form between the two layers of the pericar- 
dial sac, causing its partial or complete obliteration. 

Tuberculous forms of pericarditis may occur as miliary infiltration 
of the parietal and visceral layers of the pericardium. There may 
be serous, serofibrinous, purulent, or hemorrhagic exudate in the sac, 
or gray cheesy nodules of tubercle tissue may be present in the 
epicardial and subpericardial tissue (Ziegler, Baginsky). 

Myocarditis, circumscribed or general, may occur in all forms of 
pericarditis. The adhesive forms are complicated with myocarditis. 

Symptoms. — Pericarditis in children manifests itself by rational 
symptoms and physical signs. 

Rational Symptoms. — At the bedside, the symptoms of the differ- 
ent forms of pericarditis cannot be divided into classes. Some 
of the fibrinous or dry forms run an insidious course without giving 
any marked symptoms of the disease. On the other hand, large 
efiusions may make their appearance without any previous rational 
symptoms which are characteristic. This is the case in the forms 
of pericarditis in infants and children, which occur in septic 
conditions, in pneumonia, empyema, and in the exanthemata. If 
attention has been drawn to the heart, it will be found that 
certain symptoms may be traced to the inflammatory process 
in the pericardium. If the patients have been suffering from 
endocarditis of rheumatic origin, empyema, or one of the exan- 
themata, they show the symptoms of grave cardiac disease. They 



PERICARDITIS. 627 

have an anxious facial expression, with marked pallor and cyanosis 
of the lips. They do not, as a rule, complain of pain. The respi- 
rations are markedly increased, as is also the pulse. Older children 
may complain of pain or uneasiness in the epigastrium. They also 
show marked dyspnoea and orthopnoea. In infants there are signs 
of pain on breathing. In some of the fibrinous forms there is fever, 
but dry forms of pericarditis may run their entire course without 
it. The purulent forms give a remittent temperature-curve. The 
pulse is rapid, varying from 120 to 150. In the forms with effusion, 
the pulse is irregular. If myocarditis is present, the pulse is irreg- 
ular and persistently high, and there is an accompanying increase 
in the number of respirations. There is no case on record in which 
the diagnosis of mediastinopericarditis has been made in a child 
during life and confirmed at autopsy, nor does the so-called pulsus 
paradoxus give any assistance, since it is present in other conditions 
in childhood (Steffen). 

Physical Signs. — In pericarditis, there are the physical signs of 
the dry plastic forms and the forms with effusion into the sac. 
The signs of the dry pericarditis and those of the first stage of that 
wdth effusion are practically identical and may be considered 
together. 

Inspection. — In dry plastic pericarditis and the first stage of 
pericarditis with effusion there may be no signs to be detected by 
inspection. There may be an increased impulse, apparent to the 
eye, over the whole cardiac area to the left. When effusion takes 
place, little or no pulsation can be made out over the cardiac area 
when the patient is in the recumbent position. There may be 
distinct bulging of the cardiac area, varying with the amount of 
fluid present. No localized apex impulse is visible when the 
amounts of fluid are large. There may instead be a diffuse pulsa- 
tion over the area of the apex and toward the sternum. 

Palpation. — In dry pericarditis, and in the first stage of peri- 
carditis with effusion, there is a friction fremitus felt over the areas 
in which the friction murmur is heard. This may be at the apex, 
at the base, or along the right ventricle close to the left border of the 
sternum. 

The Apex-beat or Impulse, and its Relations to the Chest Wall in 
Pericarditis with Effusion. — As effusion takes place, it is indicated 
by certain physical signs relative t® the heart apex, and by the 
line of dulness to the left. Investigations have shown that, when 
the patient is in the recumbent posture, pericardial effusion first 
collects at the base of the heart around the great vessels. It next 
collects over the anterior surface and in the anterior-inferior cul-de- 
sac of the pericardium (Yoinitch). When the patient is recumbent 
the effusion does not necessarily push up the apex-beat. On the con- 
trary, it separates the heart from the auterior chest wall. In mod- 



628 DISEASES OF THE CIRCULATORY SYSTEM. 

erate effusion the apex-beat may still be felt in the normal position. 
As the effusion increases, the apex-beat recedes and becomes less 
discernible and more diffuse, and in large effusion may disappear. 
This is especially the case, if there is dilatation of the heart or 
adhesions at the apex. When the effusion is again absorbed, the 
apex-beat becomes evident in the former situation. 

When the patient is sitting, the pericardial effusion collects 
beneath and behind the heart, and, if the heart is not enlarged or 
held down by adhesions, the apex-beat may at first be displaced 
upward, and will be felt above and to the outside of its normal 
position. These facts will explain the failure in certain cases of 
pericarditis, to obtain the displacement of the apex -beat upward. 
In one of my oases, a boy of six years, suffering from chorea, 
endocarditis, dilated heart, and pericarditis, the apex -beat was ob- 
served in the beginning of the stage of effusion to be located in 
the sixth space, slightly outside the nipple line. Effusion having 
occurred, the apex-beat could still be observed in its former locality, 
but the area of absolute dulness indicating effusion extended beyond 
the apex, four cubic centimetres to the left of the mammillary line. 
The effusion disappeared and the apex then corresponded with the 
line of dulness of the left ventricle. 

Percussion. — In dry fibrinous pericarditis, and in the dry stage of 
pericarditis with effusion, there is no increase in the area of cardiac 
dulness directly traceable to the disease. If there is a slight di- 
latation or relaxation of the ventricle due to myocarditic compli- 
cation, the normal prsecordial dulness may be more distinct. 

The effusion must have a bulk of 40-60 grammes (1 J to 2 fluid- 
ounces) before definite signs of its presence can be obtained. 

In children, the area of dulness due to pericardial effusion does not 
have the triangular shape seen in adults. The position of the heart 
is more horizontal and its shape is retained by the distended sac. 
Thus, to the left, the dulness may extend in a curved line outside the 
situation of the nipple. Superiorly, it may extend as high as the first 
rib. It then extends in an almost horizontal line two or more centi- 
metres to the right of the sternum (Fig. 134). The line of dulness 
to the right of the sternum then extends downward in an almost 
vertical line to the liver (sixth space) (Steffen, Baginsky, Ausset). 
These facts are very important in differentiating dulness result- 
ing from pericardial effusion from dulness due to other causes. 
Even in moderate effusion there is resistance to the percussing 
finger. If the patient's position is changed from the recumbent 
to the sitting posture, the heart falls forward, the pericardial sac is 
distended, and the dulness to the left may come more toward the 
mammillary line and, to the right, toward the sternum (Bagin- 
sky). _ _ - 

Auscultation. — The friction sound is diagnostic in dry plastic 



PERICARDITIS. 



629 



pericarditis and in the first stage of pericarditis with effusion. It 
may, at the outset, be heard at the apex (Steifen), but is also heard 
to the left of the sternum over the base, or below, to the left of the 
sternum, over the fourth or fifth space. Steffen finds it in children, 
at first, most frequently at the apex. The murmur may be heard on 




Pericardial area of dulness due to effusion in boy, six years of age. Chorea, endocar- 
ditis, and pericarditis : x, apex-beat before effusion; o o o o, friction murmur; outer curved 
line sliows general shape of distended pericardial sac. 

systole or diastole, or on systole only. It may or may not accom- 
pany the valvular sounds. It is of very limited distribution, is not 
conducted, and is of a fine crepitant quality or has a rubbing or a 
rasping or clicking sound. In the case of a boy suffering from re- 
current chorea and pericarditis, there was a loud scraping friction at 
the apex with murmurs of mitral and aortic regurgitation. I was 
able in this case to confirm the statement of Walsh, that a loud peri- 
cardial friction may sometimes be heard behind, between the scapulae, 
to the left of the spine. The friction may for the first day or two 
be of a crepitant quality and then acquire a rubbing quality. I 
observed this change in a child four years of age. The patient suf- 
fered from dilatation of the left ventricle with mitral insufficiency and 
stenosis with pericarditis. The friction for two days was crepitant 
in quality and just audible over the fourth and fifth spaces, to 
the left of the left border of the sternum. After two days, the 



630 DISEASES OF THE CIRCULATORY SYSTEM. 

murmur of friction acquired a loud rubbing quality. The murmur 
is sometimes very evanescent or may disappear or reappear at short 
intervals. The sounds may be intensified by causing the patient 
to lean forward. When eifusion appears, the friction sounds 
maj^ entirely disappear, or may be heard only in areas around the 
great vessels or indistinctly over the prsecordium. A knowledge 
of these facts is important in making a diagnosis of fluid in 
the pericardial sac. The friction sounds may reappear on absorp- 
tion of fluid. Pleuropericardial friction sounds are rough or 
fine sounds obtained in children as in adults with the respiratory 
movements of the lung. They are intensified on expiration and 
disappear when respiration is momentarily suspended. They may 
be heard over any part of Ihe prsecordium. They are caused by 
the rubbing of the inflamed pleura and pericardium against each 
other. This friction is limited to one edge of. the cardiac area, 
generally the left, and is sometimes heard in the back, on the left 
side. 

The diagnosis of pericarditis can only be made from the physical 
signs. In dry plastic pericarditis and the first stages of pericarditis 
with eifusion, the friction sound is the diagnostic sign. If a peri- 
cardial friction is once obtained, careful watch sliould be kept for the 
appearance of fluid. It is not possible at the outset to differentiate 
a dry pericarditis which will remain as such, from the first stage of a 
pericarditis with effusion. 

In the stage of effusion, small amounts of fluid will sometimes 
escape diagnosis. This is likely to occur if a process such as 
empyema is in progress on the left side. The first stage of a peri- 
carditis may escape diagnosis if the friction sound is evanescent. If 
the effusion appears in considerable quantity over the great vessels, 
percussion is made in this region, especially to the right side of the 
sternum at the level of the second or third space, for an increase in 
dulness due to a distended pericardium. Absence of dulness in this 
region across the sternum and for a few centimetres to the right of 
the right border is presumptive evidence against the presence of any 
considerable effusion. If dulness exists to the right of the sternum, 
low down only on a level of the fourth interspace, there is probably 
no pericardial effusion, but, instead, dilatation of the right ventricle. 

Differential Localization by Percussion of Pleural and Pericardial 
Effusions. — In cases in which pericardial effusion is very large or 
in which there is pleural effusion into the left side of the chest, a 
question may arise as to whether there is a simple pleural effusion 
general or localized, pericardial effusion, or both. Percussion along 
the sternum will in simple left pleural effusion easily mark out the 
displaced left pleural fold. Even if there are large amounts of fluid, 
the fold of the left pleura will be found to be distinctly displaced 
toward the right border of the sternum. The pleural line will 



PERICARDITIS. 631 

never, except under very exceptional conditions, pass beyond the 
border of the sternnni to the right. If h\rge pericardial effusion is 
present, the dull note of the effusion extends beyond the right border 
of the steriumi. In left pleuritic effusion the a})ex of the heart is 
found by auscultation to be distinctly displaced to a situation 
beneath the sternum, while in pericarditis it will at first be found 
to be in the normal position and subsequently to disappear or to be 
displaced upward and out^vard. 

The prognosis of rheumatic pericarditis is good. The purulent 
forms of pericarditis are in the great majority of cases fatal, espe- 
cially in very young infants. In older children, I have seen cases 
of purulent pericarditis, due to infection from a concurrent pneumonia 
or empyema, recover with timely pericardotomy. The septic forms 
of purulent pericarditis, complicating sepsis of the newly born and 
forms of osteomyelitis, are fatal. 

The treatment of the dry fibrinous forms of pericarditis is limited 
to the relief of the pain and the treatment of the primary condition, 
rheumatism. The pain is best relieved by the administration of 
mild opiates. Codeine in small doses is efficient in many cases. I 
am not in favor of blistering the prsecordial region in children, or 
of applying a seton, as is done in adults. If the heart is tumult- 
uous, small doses of digitalis in the tincture form and the constant 
application of an ice-bag over the prjecordial region are the most 
effective remedies. Some authors believe that the ice-bag is also a 
very powerful means of limiting the inflammation. In rheumatic 
or choreic cases the salicylate of sodium is given, or if this disagrees 
with the patient, the ordinary bicarbonate of sodium in doses of 
grains x (6.5) three or four times daily. Perfect rest in bed, long- 
after the process has run its course, is indicated, on account of the ill 
effects of strain on the heart affected by myocarditic chauges which 
are undoubtedly present in many of the cases. 

When effusion has taken place, the question of the advisability 
of puncturing and exploring the pericardium always arises. It is 
very diflicult to choose the proper time for entering the pericardium. 
I have had a number of cases of pericarditis with effusion recover 
without being subjected to what is at best a hazardous procedure. I 
can only detail my own practice in these cases. I temporize until 
the orthopnoea and cyanosis are extreme and evidences of pressure 
are marked. Too nuicli importance should not be attached to ordi- 
nary symptoms. On the other hand, if the temperature is high and 
daily remits to near the normal, there may be a purulent eflusion. 
If after a reasonable length of time the patient steadily loses ground 
and the signs of effusion are marked, the pericardium should be 
entered to determine the character of the exudate. If it is serous, 
ordinary aspiration will suffice, but if purulent, the operation of peri- 
cardotomy should be performed. Pericardial puncture or incision is 
performed in the same manner as in adults. 



632 DISEASES OF THE CIRCULATORY SYSTEM. 

It may be remarked that Henoch has never punctured the peri- 
cardium. In one of his cases, post-mortem examination showed 
small sacculated purulent collections of fluid which could hardly have 
been evacuated by a single ])uncture. I found a similar condition 
post mortem in a case in which puncture of the pericardium was 
undertaken, and resulted in puncture of the heart. 

Adherent Pericardium. 

Adherent pericardium is an agglutination, localized or complete, 
of the visceral and parietal walls of the pericardial sac which becomes 
partly or completely obliterated. The condition follows either a dry 
plastic pericarditis or a pericarditis with effusion, in the stage of 
absorption. In the latter case, if the absorption of fluid has been 
observed and the redux friction-sound obtained, adhesion of the peri- 
cardium may be suspected from certain signs ; otherwise, diagnosis 
even within probable limits would in many cases be an impossibility. 
Infants and children who have withstood an attack of pericarditis, 
especially of the rheumatic form, are very prone to contract this form 
of pericarditis. In most cases it causes myocarditis of a progressive 
type ; hence the importance of understanding the condition. Hyper- 
trophy of the heart, atrophy of the heart, or dilatation of that organ 
may accompany adherence of the pericardium. 

The symptoms, especially in the rheumatic cases, develop late in 
the disease when myocarditis supervenes. The condition may prove 
fatal by progressive affection of the cardiac muscle. One of my 
cases, of rheumatic origin, showed post mortem no valvular lesion. 
There were complete obliteration of the sac and extreme dilatation. 
The symptoms are at first negative. There may be a friction sound 
or a roughening of the cardiac sounds at the base. There is in some 
cases a drawing inward of the apex area of the chest at the xiphoid 
cartilage. A wave-like undulation of the cardiac area with an increase 
of cardiac dulness is sometimes found. There may be persistent 
asystole not controllable by digitalis (See). In my cases there were 
angina, a persistently high pulse with an increase in the number of 
respirations, and in the last stages, all the symptoms of non-compen- 
satory dilatation of the ventricle which are seen in valvular disease. 
There may be a mitral systolic murmur simulating that seen in val- 
vular disease. In spite of all these symptoms, it is rarely possible to 
make a positive diagnosis during life. 

II. DISEASES OF THE HEART. 

The height of the heart and of the great vessels in children does 
not after the third year materially difier from that in the adult. 
The ratio of the transverse to the sagittal diameter of the chest 



DISEASES OF THE HEART. 633 

in newborn infants is 2 to 1, while in adults it is 3 to 1. This 
fact should not be forgotten in estimating the size of the heart in 
infants and children. What in an adult might appear to be a large 
heart, is normal in an infant or a young child. 

Position. — In the first year of life the long axis of the heart is 
more horizontal than in later childhood or in adult life (Rauchfuss). 
At the third year, the position of the heart is practically that found 
in the adult (Dwight). 

As the cliild becomes older the heart assumes more nearly the 
vertical position, and in older children the apex-beat may be found 
0.75 to 1 centimetre within the mammillary line. The situation of 
the mammillary line is variable in young children ; the nipple is 
over the fourth rib, but further removed from the midsternal line 
than in older children on account of the greater transverse as com- 
pared to the longitudinal diameter of the thorax. In older children 
the heart areas closely resemble those in the adult. In infants and 
young children there are certain variations from the adult condition 
which should be borne in mind. 

Size. — The heart is relatively larger in the infant than in the adult, 
having 0.89 per cent, of the body weight in the newborn infant, while 
in the adult it has only 0.52 per cent. (Vierordt). 

Apex-beat. — The apex-beat in the newborn infant may be felt 
higher than in the adult. On account of the greater breadth of 
heart as compared with that of the chest the apex is external to the 
mammillary line. Steffen says, that normally the apex-beat may be 
found 1 centimetre external to the mammillary line, or in the mam- 
millary line, or internal to the mammillary line. The apex -beat in 
infants and children is in the fifth space. 

Inspection. — Inspection shows in some cases an undulatory move- 
ment over the whole cardiac region. This is normal as long as it is 
confined to the left of the sternum, but an undulatory movement to 
the right of the sternum is probably indicative of dilatation of 
the right ventricle with or without hypertrophy. In rachitis the 
cardiac region is sometimes unduly prominent. This condition 
must be distinguished from the more pronounced fulness in the 
prsecordium occurring in cases of hypertrophy or of pericardial 
effusion. The apex -beat should not be mistaken for an apparent 
apex-beat which is sometimes seen in young children in whom 
the intercostal space to the left of the large cardiac dulness is 
raised with each pulsation of the apex. Percussion in these cases 
will show the apex to be situated elsewhere to the left and 
downward. In some cases the apex, instead of pushing the in- 
tercostal space forward, draws it distinctly inward. This is in part 
due to adhesions between the heart, pericardium, and parts external 
to the pericardium. When children are struggling, the systolic im- 
pulse of the heart is seen to be communicated to both the carotid 



634 DISEASES OF THE CIRCULATORY SYSTEM. 

artery and the jugular vein, the vein getting its impulse from its 
proximity to the artery. The vein may be found to be collapsed 
and the artery to show an impulse on systole. 

Palpation. — The following points may be determined by palpa- 
tion with the tips of the fingers or full palm : 

1. Location of the apex-beat. 

2. Sometimes the location of the left boundary of the heart. 

3. The force of the systole, hypertrophy or dilatation of the 
heart, especially if pulsation is evident to the right of the sternum. 

4. Transposition of the heart to the right. 

5. The closure of the valves of the pulmonary artery in the 
second or third space near the sternum. 

6. Murmurs which cause friction (pericardial) or thrills (endo- 
cardial). 

7. Rhythm of the heart action. 

Auscultation. — In infancy the muscular quality of the first sound 
is not apparent. The heart-sounds have more the character of the 
tick-tack of a watch. The muscular character of the first sound 
fully develops toward the second year of life. All through infancy 
and childhood there is a natural accentuation of the second pul- 
monic sound. Too much importance should not be attached to 
the accentuation even if it is marked. 

Percussion. — The percussion of the heart has been the subject 
of much refinement of methods, which only tends to confuse a simple 
matter. The following method will be found suitable for most 
clinical purposes : 

The lines of demarcation are the midsternal line and a parallel 
line running through the left nipple. All reckonings as to the 
limits of cardiac dulness may be safely made from these lines, and 
such figures will be understood by all physicians. The right border 
of the sternum is not a good line to reckon from, since the width 
of the sternum varies. The recumbent posture is preferable in 
infants ; both the recumbent and upright positions are suitable in 
older children. 

Method of Locating the Line of Dulness of the Left Ventricle. — To 
locate the external boundary of the ventricle, we begin to percuss in 
the lines parallel with the second, third, fourth, and fifth ribs toward 
the heart, from the axillary line or the anterior axillary line. To 
percuss from the midsternal line outward does not in children give 
as good results. 

To locate the external border of the right ventricle, we percuss 
along the fourth rib or fourth space toward the sternum from the 
right mammillary line. In young infants a portion of the right 
auricle and ventricle will be found as high as the junction of the 
second rib and the sternum (Symington), but it is an ultra-refine- 
ment of percussion to try to make out the projection of this part of 



DISEASES OF THE HEART. 



636 



the right auricle to the right of the sternum. It is found, anatom- 
ically, that the curve of the auricle to the right of the sternum 
begins at the third space, and is most marked behind the fourth 
costal cartilage. It is sufficient for clinical purposes to make 







Fig. 135. 








i 


mm^~ ''p^i 


1 




/ 


1 




w 




1: 

/ 


% ■ 




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Form of the normal relative cardiac dulness in a child two and one-half years of age. 



out this most projecting part of the heart to the right of and 
behind the sternum. 

The apex of the heart is generally made out by percussing along 
the fifth rib or fifth space from the antero- lateral axillary line toward 
the midsternal line. The external boundary of the left ventricle is 
in children slightly outside the apex-beat. The area of cardiac 
dulness which is absolute and which is uncovered by lung can best 
be made out by percussing from above downward over the cardiac 
area. In children or infants this area cannot be marked out as 
definitely as in the adult. The younger the child or infant, the 
greater the difficulty. In infants and children interest centres 
rather in the apparent size of the heart (relative dulness) than in the 
area uncovered by lung. 

The dulness extends to the right and left of the midsternal line, 



636 DISEASES OF THE CIRCULATORY SYSTEM. 

at a level with the fourth rib, as is indicated by the following figures 
compiled from SteflPen's tables : 

Infants under one year right v. 4 to 6.5 cm. to right. 

left V. 8.5 to 6.25 cm. to left. 
Children one to two years , right v. 4 to 6.5 cm. to right. 

left V. 4 to 7.25 cm. to left. 
Children two to three years right v. 4.5 to 7.5 cm. to right. 

left V. 4.5 to 6.5 cm. to left. 
Children five to six years right v. 5.5 to 7.25 cm. to right. 

left V. 5 to 8.25 cm. to left. 
Children nine to ten years right v. 5.5 to 8.5 cm. to right. 

left V. 5.5 to 8.5 cm. to left. 

Enough has been selected to show that the actual size of the heart 
as obtained by percussion in infants and children is extremely vari- 
able, and the examiner must be guided by the relative size. 

Congenital Heart Disease. 

Congenital heart disease may be suspected from certain physical 
signs which occur in that condition and are in a sense characteristic 
of it. These are cyanosis, changes in the area of cardiac dul- 
ness, and the presence of characteristic murmurs. 

Cyanosis. — The cyanosis which is characteristic of congenital 
heart disease does not occur in any of the ac(piired cardiac lesions. 
It is most common in the congenital forms of pulmonary stenosis of 
the artery, conns, or ostium. On the other hand, it may be absent 
in marked congenital disease, as in deficient ventricular septum and 
open ductus arteriosus. In tlie latter disease it may appear late in 
the condition, only at intervals, or not at all. It may be absent at 
birth and aj)})ear in infancy or chiklhood. 

Cardiac Dilatation and Hypertrophy. — The presence of a 
murmur of congenital origin does not necessarily indicate change 
in the area of cardiac dulness. In fact, a normal cardiac area is 
sometimes evidence of the congenital character of a murmur. 
Hypertrophy of tlie left ventricle should be present with hyper- 
trophy of the right ventricle, and a murmur to indicate open 
ductus arteriosus. Dilatation of the right ventricle is of value 
when present with a murmur indicating stenosis at the pulmo- 
nary valve. On the other hand, marked congenital defects may 
exist without any change in the size of the ventricle. Moreover, 
if the cardiac area is enlarged and the a})ex impulse weak, con- 
genital disease may be suspected. The weak a})ex impulse indicates 
dilatiition. 

Murmurs. — The murmur most characteristic of congenital heart 
disease is a systolic murmur at the situation of the space between 
the second and third costal cartilage to the left of the sternum, and 
not conducted into the arteries of the neck. It is only when there 



CONGENITAL HEART DISEASE 637 

are complicated defects that murmurs are conducted into the carotids 
(open ductus arteriosus). 

Fcrtal endocarditis affecting the tricuspid or mitral valves is 
rare, and therefore murnuirs of congenital origin are rare at these 
valves. 

Diastolic murmurs are, so far as congenital lesions are concerned, 
of theoretical interest only. 

Systolic nuirnuirs, such as those heard in cases of defects of 
the ventricular septum, and which cannot be attributed to valvular 
disease, occur at the pulmonic valves. In these cases the murmur has 
no point of greatest intensity, but is heard not only at the valve, but 
also over the whole prsecordium. The valvular sounds are dis- 
tinct. The most marked congenital defects or disease of the heart 
may exist without any murmur or other physical signs during life. 

In simple pulmonary stenosis, the second pulmonic sound is 
weak ; in cases complicated with open ductus arteriosus and liyper- 
trophy of the ventricles^ it is accentuated ; in cases of pulmo- 
nary stenosis and deficient ventricular septum, it is either weak or 
very low. 

The positive diagnosis of the exact lesion in congenital heart 
disease is in many cases impossible. The reason for this is easily 
found in the fact that if the patient lives longer than the first 
year, the lesion is rarely simple, but occurs with other congenital 
defects in the heart. Another cause is the rarity of autopsies on 
uncomplicated cases which have been carefully studied during life. 
Lastly, in complex cases, even if the diagnosis has been confirmed 
at autopsy, it is impossible to say to w^hat degree the lesion diagnosed 
and the other complicating conditions found at autopsy have been 
the cause of the signs and symptoms found during life. The physi- 
cal signs of congenital heart disease vary as the lesion is a simple 
one or is combined with other congenital defects. The following 
classification of congenital heart disease of developmental or fa^tal 
endocarditic origin will be found useful in clinical work : 

1. Septum DefecU. — Auricular (foramen ovale) ; ventricular. 

2. Pulmonary Arto-y. — Stenosis of the conns, trunk, or ostium : 
(a) simple cases (before the end of the first year of life) ; (6) com- 
plicated cases with open foramen ovale or ductus arteriosus, defect 
of the ventricular septum, or transposition of the great vessels. 

3. Aortic Valve Stenosis or General Contraction of the Aortic Sys- 
tem. — The first may be due to developmental defect or to fa>tal endo- 
carditis ; the second, to developmental defect. All aortic conditions 
anomalous in character have, so far as is known, not been posi- 
tively diagnosed during childhood. 

4. VaivuJar anomalies of the semilimar valves, due to foetal 
endocarditis or developmental irregularities are of purely scientific 
interest. 



638 



DISEASES OF THE CIRCULATORY SYSTEM. 



5. Open Ductus Arteriosus or Botalli. — (o) 8iini)lo ; (6) combined 
with septum defects or pulmonary stenosis. 

6. Transposition of the Heart and Congenital Anomalies of the 
Pericardium (of purely scientific interest). 

From the above account, which I l^ive modified for practical use 
from the classification of Yierordt, it will be seen that only the con- 
genital anomalies of the auricular ventricular se})tum, the pulmonary 
artery, and the ductus arteriosus Botalli are of interest to the clinician. 



Stenosis of the Pulmonary Artery, Conus, or Ostium. 

This is the most common of all congenital heart lesions. 



If 



found after the thirteenth month of life, it is in most cases combined 

Fig. 136. 




Congenital pnhnoimry stenosis with open ductus Botalli, as shown by a dull area in the 
second space above tiie base of the heart; loud systolic murmur at the "pulmonary orifice ; 
clubbed tingers, cyanosis of the general surface, symptoms of chronic bronchitis ; dyspnoea 
on exertion. Boy, twelve years of age. 

with a congenital deficiency of the septum ventricuh)rum. Rauchfuss 
found a simple stenosis in only 10 per cent, of all the ])ublished 
cases. Most of the cases are due to fetal endocarditis. 



STENOSIS OF THE PULMONARY ARTERY, CON US, OR OSTIUM. 639 

Physical iSigns. — Simple stenosis of the artery, conns, or ostium, 
found only before the tliirteentli month (Rokitansky). 

Cyanosis. — Early and congenital cyanosis and signs of venous 
stasis, such as clubbed extremities of the fingers, even in young 
infants. In cases which are met in later life the clubbing of the 
extremities of the fingers and cyanosis of the finger-tips are marked. 



Fk;. 1:57. 




Clubbed fingers of congenital heart disease. Child six years of age. 

Murmur. — A systolic murmur heard with greatest intensity at the 
situation of the pulmonary valve to the left of the sternum, between 
the second and third costal cartilages, and not conducted into the 
carotids. A weakened second sound at the pulmonary valve ; dila- 
tation of the right ventricle. 

Simple stenosis is found in infants, but is rare. In most cases 
there are also present congenital defect of the ventricular septum, 
open ductus arteriosus, tricuspid changes, or the aorta arises from 
the right ventricle or both ventricles. The following facts should be 
kept in mind in the diagnosis of cases occurring after the thirteenth 
month of life : 



640 DISEASES OF THE CIRCULATORY SYSTEM. 

If the above signs are present with a weakened second pulmonic 
sound, there being absolutely no conduction of the murmur into the 
carotids, it may be assumed that there is a pulmonary stenosis with 
an open foramen ovale. 

Conduction of the murmur into the arteries of the neck, with a 
very distinct though not accentuated second pulmonic sound, points 
to the presence of a septum defect with a pulmonary stenosis. 

An accentuated second pulmonic sound with conduction of a 
murmur of a loud buzzing character into the subclavian and carotids, 
and a hypertrophy of the right and also of the left ventricle, will sup- 
port the theory of a pulmonary stenosis with a patency of the ductus 
arteriosus (Fig. 136) (Hochsinger). In these cases of open ductus 
arteriosus there is a thrill and a distinctly defined area of dulness in 
the second space to the left of the sternum above the base of the 
heart. This dulness is of great diagnostic import. It is due to the 
dilated great vessels at the base of the heart. 

As an exception to the above classification, may be mentioned the 
case of Sansom, in which cyanosis and extreme anaemia were pres- 
ent. In rare cases, the second pulmonary sound may be very low. 
The murmur may be conducted into the axilla, the right heart not 
being dilated. 

Open Ductus Arteriosus or Ductus Botalli. 

This is a very rare congenital defect. There are in the literature 
only 20 cases of uncomplicated open ductus arteriosus in which the 
autopsy confirmed the clinical diagnosis. Of these, only 5 occurred 
in infants under one year of age, and 5 others ranged from the first 
to the tenth year (Yierordt). The complicated cases occur with 
stenosis of the pulmonary artery, septum defects of small extent, and 
open foramen ovale. 

Physical Signs. — Cyanosis is not present in the majority of cases, 
or if present is so only intermittently and is not marked. 

The murmur is a loud buzzing systolic murmur heard with 
greatest intensity over the pulmonary artery, and not conducted 
downward, but conducted to the left of the sternum into the veins 
of the neck (Hochsinger). 

There is an accentuated second pulmonic sound which can be 
heard in the carotids. 

Right Ventricle. — The presence of hypertrophy of the right ven- 
tricle tends to confirm the diagnosis ; if the left ventricle is also 
hypertrophied, greater certainty is added. This is of great moment, 
since hypertrophy of the left ventricle is not present in any of 
the other congenital defects, except those connected with the 
anomalies of the aorta and aortic system and which have only a 
scientific value, since the literature contains no cases which have 



CONGENITAL DEFICIENCY OF THE VENTRICULAR SEPTUM. 641 

been diagnosed during life. The diilness in the second space referred 
to under Pulmonic Stenosis is also of value. 

Congenital Defects of the Auricular Ventricular Septum ; De- 
fects of Auricular Septum ; Open Foramen Ovale. 

Inasmuch as 44 per cent, of the autopsies upon individuals who 
during life showed absolutely no signs of cardiac disturbances reveal 
a patency of the foramen ovale, the diagnosis of the condition as an 
uncomplicated entity should be made with great reserve. This con- 
genital defect is generally found to exist in connection with other 
defects of a congenital nature (stenosis of the pulmonary artery). 

Cyanosis has been found in all the cases in which autopsy has 
been made. In a case recorded by Foster, there was cyanosis with 
a varying systolic and presystolic murmur at the sternal end of 
the third or fourth costal cartilage. 

Walshe says that it can hardly be asserted positively that a 
patency of the foramen ovale may of itself cause a murmur. 

Congenital Deficiency of the Ventricular Septum — 
Maladie de Roger. 

Autopsies have shown that this condition may exist during life 
without giving any signs of its presence. Moreover, it is so often 
combined with other congenital heart anomalies, such as stenosis of 
the pulmonary artery or ostium, that the signs of the ventricular 
condition must of necessity be obscured by those of the complicating 
defect. 

Cyanosis has been present in some cases of uncomplicated ven- 
tricular septum defect (Miiller) and absent in others. It is present 
in the cases complicated with pulmonary stenosis. 

Murmur. — According to Roger, a loud systolic murmur is heard 
over the whole prsecordium, toward the median line, over the upper 
third of the cardiac area. According to others (Miiller), the murmur 
has no special point of greatest intensity. It is not conducted into 
the vessels of the neck. 

Rauchfuss calls attention to the fact that with this murmur the 
distinct valvular character of the heart-sounds at the various valves 
should be heard. The case of Miiller was that of a cyanotic 
infant two months old. A loud murmur having no special point 
of greatest intensity was heard over the whole cardiac area. The 
valvular sounds were distinctly heard. Autopsy showed uncom^ 
plicated defect of the ventricular septum. 

41 



642 DISEASES OF THE CIRCULATORY SYSTEM. 

Acute Endocarditis. 

Acute endocarditis is an inflammation of the lining membrane of 
the heart. That covering the valves and their immediate vicinity is 
the area generally affected. There is also an inflammation, slight or 
marked, of the muscle tissue of the heart, and in some cases there 
is inflammation of the pericardium. Endocarditis thus involves 
structures of the heart other than the endocardium. Acute endo- 
carditis may be benign or malignant. Between the two extremes, 
there are all gradations as to severity. All forms of endocarditis 
are caused by infection which in the malignant variety is of the 
severest septic type. Foetal endocarditis affects the right side of 
the heart ; after birth, the left heart is chiefly aflected. The condition 
is less frequent before than after the fifth year of life, and occurs 
with equal frequency among boys and girls (Steffen). 

Etiology. — Acute endocarditis occurs most frequently with acute 
articular rheumatism, but may appear in any infectious disease. It 
is often found in scarlet fever ; less often in measles. I have seen 
it in rare cases of erythema nodosum (2 cases). It may occur with ty- 
phoid fever, diphtheria, influenza, pneumonia (Netter), cerebro-spinal 
meningitis, and tuberculosis. In fact, all forms of sepsis, such as 
osteomyelitis, either foetal or in the newborn infant or in children, 
may be accompanied by endocarditis. Endocarditis is present in 
16 per cent, of the cases of chorea and is always ])resent in fatal 
cases of that disease. 

Bacteriology. — The most important bacteria bearing an etiolog- 
ical relationship to endocarditis are the streptococci of the various 
varieties and the Staphylococcus pyogenes. Harbitz divides endo- 
carditis into the infectious and the non-infectious varieties. He found 
bacteria in the vegetations in most of the infectious cases, streptococci 
in 39.5 per cent, and staphylococci in 18.6 per cent, of the cases; 
other bacteria, such as the pneumococci, were also found. The cases 
in which no bacteria were found were healed cases. He thinks that 
the staphylococci most often cause pysemic endocarditis with ulcera- 
tions and metastatic abscess. Welch has, however, found strepto- 
cocci in ulcerative endocarditis, and does not fully accept the view 
of Harbitz. The Diplococcus pneumoniae is next in importance as an 
etiological factor. Wright found the Bacillus diphtherise in one case. 
Other bacteria, such as the Gonococcus, the Bacillus endocarditidis 
griseus (Weichselbaum), the Micrococcus endocarditidis rugatus and 
capsulatus, the Diplococcus tenuis (Klemperer), have been found in 
cases of adult endocarditis. Although they are all, as well as the 
Bacillus typhosus, doubtless capable of causing the same process in 
children, actual clinical cases are still to be published. 

All forms of endocarditis are thus septic processes due to the 
circulation in the blood of bacteria or their toxins. In some cases 



ACUTE ENDOCARDITIS. 643 

it is possible to discover the point of entrance of the bacteria into 
the circulation, in others, it cannot be fixed upon. The forms of 
endocarditis are not so uncommon in infants as is supposed. The 
tonsil is a great avenue for the entrance of bacteria or toxins into 
the circulation (Cheadle). It is believed that many cases of endo- 
carditis in cliildren originate in this manner (Packard). I have 
frequently met with endocarditis in which the only other clinical 
manifestation was a slight redness or swelling of the tonsils. The 
integrity of the endothelium of the endocardium must be compro- 
mised if bacteria have invaded the tissue of the valvular endocar- 
dium (Prudden). It is supposed that the toxins produced by the 
bacteria circulating in the blood reduce the resistance of the endo- 
thelial lining of the endocardium, thus preparing the soil for bac- 
terial invasion. 

Morbid Anatomy. — In some cases the only lesion is a swelling 
of the valves. They are thickened and succulent, their surface being 
smooth. The basement substance is swollen and there is an increase 
of connective-tissue cells (Delafield). In other cases the borders of 
the valves present transparent, gelatinous, whitish-yellow or reddish 
formations, varying from the size of a pin's head to that of a bean. 
These are irregular in shape, cover both surfaces of the valves, and 
may be single or multiple. They are also seen on the chordae 
tendinese. The free border of the valve is warty or papillomatous 
(endocarditis verrucosa or polyposa) (Ziegler). The papillae may ap- 
pear on the free surface of the valves. There may be a loss of sub- 
stance with the formation of adherent thrombi of a whitish or reddish 
color and of tenacious consistency (endocarditis ulcerosa). Small foci 
of pus may be present in the heart substance (endocarditis pustulosa). 
Bacterial invasion of the surface of the valves results in loss of sub- 
stance, formation of thrombi, and changes in the nuclei of the con- 
nective tissue (necrobiosis). The mitral valve being more vascular is 
sooner affected than the aortic or pulmonary valves. Exudation on 
the valve is replaced by new connective tissue ; excrescences and new 
formations become permanent. If the bacteria penetrate deeply, 
thickening of the valve results. Large thrombi are organized, and 
the valves become shrunken and distorted. Ulceration and loss of 
substance may result in perforation of the valves. The thrombi 
just mentioned are sometimes made up of blood-plates ; in other 
cases leucocytes, blood-cells, and fibrin in varying amounts are 
present. 

There may be exudative pericarditis. The myocardium is the 
seat of degeneration, which leads to dilatation, or to abscess or 
aneurism of the heart muscle. Through the separation of portions 
of the thrombi or of the vegetations on the valves, these particles 
may be carried into the circulation. Containing, as they do, bacteria 



644 



DISEASES OF THE CIRCULATORY SYSTEM. 



(mycotic emboli), they cause secondary infections with necrosis or 
abscess in the kidney, spleen, and brain. 

The symptoms of acute endocarditis are those of some general 
infection. They are not in infants and children so characteristic as 
to direct attention to the heart. Infants cannot and children do not 



Fig. 138. 


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RESP. $??5J $1 5!?5J|S?!S ?S?;S=?|S 


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Endocarditis complicating influenza. Second week of the illness. Mitral systolic mumur 
developed under observation. Female child, four years of age. 

complain of pain, palpitations, or feelings of uneasiness in the heart 
region as adults sometimes do, and therefore unless the heart is care- 
fully examined as a routine procedure, the simple cases of endocar- 
ditis will escape observation. The most interesting cases are those 
which begin with all the symptoms of an attack of influenza or 
tonsillitis. There are fever, rapid pulse, and an increase of the 
respirations to 36 or 40. The fever, however, does not subside in 
the time occupied by the course of one of the above affections ; it 
continues high, 103°-104°-105° F. (39.4°-40.5° C), with morning 
or afternoon remissions. In such cases a most careful examination 
of the lungs and other organs, fails to reveal anything abnormal. 
The heart, however, shows the presence of endocardial inflammation. 
In some obscure cases, there is an increasing pallor with a slight daily 
rise of a half a degree or a degree in body temperature, which will 
continue for days or even weeks and give rise to a suspicion of 
paludal poisoning. There is also an increasing pallor. Examination 
of the heart reveals the lesion. In other cases there are a very 
slight but increasing pallor, weakness, and indefinite pains in the 
bones and joints. In children, more than in the adult subject, we are 
apt to have monarticular affections of a rheumatic nature. I have 
seen several cases of monarticular joint-affection with an endocardial 
murmur in childhood. One case was that of a child two years and 
eight months of age, another recent case was that of a child eight 
years of age. In the one case the ankle was swollen, painful, and 
slightly reddened. There was no temperature. There had been 
slight pain in one knee some days previous to the ankle-affection. 



SEPTIC, ULCERATIVE, OB MALIGNANT END OCAEDITIS. 645 

In the other case the metatarsal and phalangeal joint of the small 
toe was involved. In young children the joints may be painfyil, 
and still no history of joint-pain will be given, and the first in- 
dication of pain is a decided limp in walking. The rheumatic 
oases are as a rule easily diagnosed. The heart should be regu- 
larly examined in such cases. The endocarditis which compli- 
cates chorea sometimes runs its entire course without any marked 
rise in the body temperature. I have, however, been able in 
such cases to confirm the statement of Jiirgensen, that the normal 
diurnal temperature variations are distorted — that is to say, the 
morning temperature may be higher than the evening tempera- 
ture. In other cases of chorea there is a distinct rise of tem- 
perature without any increase of the respirations and pulse-rate 
during the active stage of the endocarditis. After the symptoms 
of chorea have begun to decline there is occasionally a rise of 
temperature lasting a day or more, which may indicate a slight 
recurrence of the endocarditis. In other cases I have observed 
a subnormal temperature of a degree or more lasting for days. This 

Fig. 139. 



8 2 8 8 2 8 8 2 



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^ 



i 



5? 



I 



I 



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i 



Chronic cardiac disease, hypertrophy, and dilatation of the left and right ventricles. 
Enlarged liver and spleen, ascites, cyanosis, recurrent attacks of endocarditis. Tempera- 
ture by rectum shows a subnormal range. Boy, twelve years of age. 

occurred in a case of recurrent endocarditis. Thus the temperature 
is not at all characteristic. The heart in children is extremely ir- 
regular. It may vary from 60 to 120 per minute within a few days, 
and may vary at different times of the same day. Under such con- 
ditions it may be surmised that there is a myocarditis. The res- 
pirations are increased. The children do not complain of the heart. 
In pneumonia, scarlet fever, and measles, the endocarditis is 
masked by the symptoms of the primary disease. 



Septic, Ulcerative, or Malignant Endocarditis. 

This form of endocarditis is rare in infants and children. Adams 
collected from the literature 47 cases in children. The sexes were 
about equally affected. Three cases were congenital and 8 were 



646 



DISEASES OF THE CIRCULATORY SYSTEM. 



^Ye years of age or under. The others ranged up to fourteen 
years. The trend of opinion (Adams) supports the contention 
of Lazarus, Barlow, and Weichselbaum, that these cases differ 
from the benign cases only in regard to severity. Dreschfeld 
divides these cases into the following classes : (a) the primary 
form, (h) the form complicating septic disease, (c) the form compli- 
cating pneumonia and meningitis, (d) the form which occurs as a 
mixed infection due to septic organisms in the acute infectious 
fevers or which is secondary to the rheumatic affections of the valves. 
I have recently observed two cases of septic endocarditis. In one, in 
a boy with osteomyelitis of the tibia, staphylococci were found in the 
blood during life. In the other case, which followed a pneumonia, 
streptoccoci were found in the blood during life. In the former case 
hemorrhagic symptoms and signs of severe cardiac disease, such as 



Fig. 140. 



15109. r+ 




5£S S ggS_S 5 ? £|ss|£i|? S£g£S 



Fatal septic endocarditis following a pneumonia. Streptococci found by culture in the blood 
during life. Girl, eight years of age. 

gallop-rhythm, were observed. The latter case was seen in my hos- 
pital service. The child, a girl of eight years, had had a pneumonia 
three weeks previous to her admission. She had apparently recovered, 
had sat up in bed after ten days, and was about. A day before her 
admission the temperature mounted to 104° F. (40° C), she vom- 
ited, and had diarrhoea. The child showed much prostration, and 
on examination an area of consolidation was found in the right 
lung behind. She had an active endocarditis giving a mitral sys- 
tolic murmur. The liver and spleen were large ; the temperature 
rose and fell twice daily, chills and dyspnoeic attacks preceding each 
rise. The temperature subsided to the normal or subnormal after each 
rise. There were nausea, vomiting, and signs of cardiac failure. The 
heart did not at first show any enlarged area of dulness. After a few 
days the left ventricle showed an increased area of dulness to the 



SEPTIC, ULCERATIVE, OR MALIGNANT ENDOCARDITIS. 647 

extent of 2 to 3 centimetres outside the nipple-line (acute dilatation), 
with diffusion of the apex -beat. The right ventricle was dilated. 
With the extreme fluctuations of temperature, the child became deli- 
rious. The heart, as at the time of admission, showed a mitral 
systolic murmur. After ten days petechise appeared, first on the 
neck and upper thoracic region, and increased both in number and 
extent. The face and eyes became oedematous (cardiac failure). The 
patient became unconscious and died in coma with Cheyne-Stokes 
respiratory phenomena. The blood withdrawn during life showed in 
culture the presence of long streptococci. 

The diagnosis of septic endocarditis rests on the history and 
the presence of cardiac signs, the prostration, the great fluctuations 
in temperature resembling those in sinus thrombosis in ear disease, 
the onset of chills and delirium, the presence of petechise, and 
lastly on the results of examination of the blood for bacteria. 

Of great interest in this connection, are the cases of chronic 
recurrent endocarditis which toward the close of the disease have 
certain symptoms resembling those of the septic or so-called ma- 
lignant cases. In a child of ten years suffering from chronic 
recurrent rheumatic endocarditis, there was toward the close of the 
illness a period during which phlebitis with thrombosis of the deep 
veins of the neck and arms on both sides and oedema of the corre- 
sponding extremities developed successively. After a few weeks the 
symptoms of phlebitis and thrombosis gradually subsided and there 
was a period of a few weeks during which the patient was much im- 
proved. The fever and anasarca subsided and the heart action was 
good. Before the fatal issue the endocarditis recurred and there were 
fever and what appeared to be significant petechise on various portions 
of the body. The case was a rheumatic one and had been under ob- 
servation for two years. Its outcome gives weight to the theory 
that a seemingly benign endocarditis may at any time take on a ma- 
lignant or septic nature. 

Physical Signs of Acute Endocarditis. — A murmur which 
develops while a child is under observation is indicative of acute 
endocarditis. 

Inspection may reveal nothing abnormal, or there may be extreme 
irregularity of the action of the heart. There may be increased 
action, as evinced by visible pulsation over the cardiac area. 

Palpation also may reveal nothing abnormal ; there may be a 
thrill over the apex. 

Percussion at first reveals nothing. In some cases there is a 
slight dilatation of the left ventricle (Steffen) as the disease pro- 
gresses. I have seen this dilatation in cases in which the condition 
had existed for a week. During convalescence the dilatation may 
retrograde and the heart confines return to their normal limits. 

Auscultation. — In the majority of cases, a soft systolic murmur 



648 



DISEASES OF THE CIRCULATORY SYSTEM. 



is heard over the apex and the mitral area. There is rarely a pre- 
systolic murmur. There may be murmurs at the other valves, 
having the characteristics of the same murnmrs in the adult. In 
any acute disease, the physician should be careful to observe a mur- 
mur very carefully before pronouncing it organic. I have found 
murmurs, especially in typhoid fever in young and older children, 

Fig. 141. 




Chronic cardiac disease; great cardiac dilatation; recurrent atlaclvs of endocarditis-, 
phlebitis and thrombosis of the deep veins of the neck and arm on both sides successively ; 
oedema of the corresponding arm and forearm ; great dilatation of the superficial cervical 
and thoracic veins. Female, ten years of age. 



which appeared and disappeared. Such murmurs are hsemic or myo~ 
carditic and functional ; they are very gentle, generally systolic, and 
are limited very closely to the apex or pulmonic area. They are not 
conducted and there are no positive signs of dilatation. Jacobi has 
described pulmonic murmurs in very young infants, which were at 



SEPTIC, ULCERATIVE, OR MALIGNANT ENDOCARDITIS. 649 

autopsy shown to be functional. On the other hand, if a murmur 
is distributed over a valvular area, takes the place of the valvular 
sound, is conducted into the arteries, and occurs in connection with 
signs of dilatation, the physician is justified, acute symptoms being 
in evidence, in assuming the presence of organic disease. 

Course and Prognosis. — Many cases of endocarditis, especially 
those not of rheumatic origin, run their course, do not recur, and in 
after-life give no symptoms referable to the heart. Others run an 
acute course without developing any physical signs until convales- 
cence. I have seen such forms follow chorea. The murmur devel- 
ops in the intervals of freedom from symptoms of chorea. Rheumatic 
cases are likely to recur, and in this tendency lies the danger. The 
prognosis as to immediate recovery is very good in all of the ordi- 
narily severe cases of acute endocarditis. The severer septic or 
malignant cases give a grave prognosis. The future of cases of 







Fig. 142. 








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Recurrent endocarditis with acute articular rheumatism which developed under observation. 
Boy, twelve years of age. 

acute endocarditis which have recovered will depend very much on 
the immediate management. I have seen patients who had been 
allowed to be up and about too early and to participate in sports, 
develop after a few months symptoms resembling those seen in 
acute dilatation due to heart strain. These cases .show a marked 
dyspnoea on exertion and cyanosis after play. The children are 
easily fatigued. They have pain and uneasiness over the region of 
the heart after running. On percussion an abnormally large heart 
area is found. 

The treatment of acute endocarditis is directed toward limiting 
the damage done by the disease to the heart. Rest in bed is neces- 
sary. The patient should not be allow^ed to maintain the sitting 
posture, but should be recumbent. The rest should be continued 
long after the subsidence of the active symptoms. The symptoms 
and physical signs are the guides as to its duration. If there have 
been marked disturbance of the heart action and distinct dilatation 
of the ventricle with signs of myocarditis such as great irregularity 
of the pulse, the stay in bed should be prolonged for weeks. 



650 DISEASES OF THE CIRCULATORY SYSTEM. 

If the action of the heart is rapid and tumultuous, an ice-bag 
should be placed over the cardiac area. This remedy is also useful 
in cases in which the heart action is not very rapid, but in which 
there are nevertheless signs of active inflammatory disturbances. 

Salicylate of sodium is a favorite remedy, not only in cases 
with a rheumatic history, but also in septic cases. The dosage is 
grains j to ij (0.6—0.12) every few hours for infants and young 
children ; older children receive more. Some children have stomach 
pains and disturbances after taking salicylates. There must then in 
the rheumatic cases be substituted some alkali, such as bicarbon- 
ate of sodium. I have administered aspirin in many cases with ap- 
parent benefit. A few drops of the tincture of digitalis will be use- 
ful in regulating the heart action late in the disease. Digitalis is 
given for periods of a few days and then suspended for a time, after 
which it may again be given if necessary. Care should be taken to 
support but not to drive the heart. The diet should be light, fluid, 
and easily assimilable. The bowels are best regulated with some 
saline cathartic or by rectal enemata. 

The temperature, if high, may be treated in the same way as in 
other acute diseases. Baths of low temperature should not be given. 
The temperature in this disease is of so short duration that in the 
majority of cases sponging with cold water is eifective. The man- 
agement of choreic cases Avill be discussed in the section on Chorea. 

The injection of antistreptococcic serum in the septic cases has 
not given satisfactory results. 

Chronic Valvular Disease of the Heart. 

The lesions in chronic valvular disease in infancy and childhood 
are the same as in the adult subject. 

The etiology has been considered in the section on Endocarditis. 

Frequency. — Of 70 of my cases of chronic valvular disease, 37 
were of the female and 33 of the male sex ; 2 were below the age 
of two years ; 24 from the second to the fifth year, and 39 from the 
fifth to* the tenth year of life. In 50 of the 70 cases the mitral 
valve was involved, causing either a systolic or a diastolic murmur, 
or both. The following table will give an idea of the relative fre- 
quency of the valvular lesions : 

Mitral insufficiency ! 26 cases. 

Mitral stenosis 6 *• 

Mitral insufficiency and stenosis 18 " 

Aortic stenosis 6 " 

Aortic stenosis and insufficiency 1 case. 

Endocardial and pericardial disease 5 cases. 

Combined lesions of mitral and aortic valves 8 " 

The physical signs, the reservations noted in the section on 
cardiac murmurs being made, are the same as in the adult subject. 




CHRONIC VALVULAR DISEASE OF THE HEART. 651 

On the other hand, certain characteristics of the disease in childhood 
are not common to the adult subject. There are cases of chronic 
cardiac disease in infancy and childhood which escape recognition 
because the heart is not examined with sufficient care. Murmurs of 
mild intensity pass unrecognized. 

There are cases of endocarditis which run an obscure course, give 
very few symptoms, and which are apt to recur at the onset of 
tonsillitis or an attack of influenza. These cases of chronic endo- 
cardial disease give very few symptoms in the intervals between the 
attacks. There may be obscure pains in the limbs or joints which 
are not interpreted by the physician as purely rheumatic, but are 
believed to be of a grippal char- 
acter. The patients may eventu- Fig. 143. 
ally develop symptoms of seri- 
ous cardiac insufficiency. The 
cases of chronic valvular dis- 
ease resulting from an attack 
of some infectious disease may 
leave the heart little com])ro- 
mised. It is true that upon ex- 
amination a cardiac murmur 
which may be marked or slight ^,. , .^ , . ^ . 

. Ill, 1 Simple mitral insufficiencv ; dilatation of the 

IS heard, but the cases have no left ventricle. Glrl, six years of age. 

subjective symptoms. They 

have what is called by the German School a healed endocarditis. 
They may, however, develop serious cardiac symptoms at the onset 
of an infection of the gut or other organs. The heart in these cases 
may be called irritable. The patients do not develop inflamma- 
tion of the endocardium or pericardium as do the rheumatic cases. 
On slight disturbance of the gut or intestines, such a heart, even 
when there is no fever, acts very much like a hypertrophied organ. 
There is an increase not only of the frequency, but also of the force 
of the heart's impulse. The vessels are also affected, and there is a 
bounding full pulse at the radial. As a result of the infection and 
of the congestion brought about by the increased action of the heart, 
there will be albumin and casts in the urine. These symptoms sub- 
side and do not recur except at long intervals. In the intervals, 
with the exception of a valvular nuirmur, there are absolutely no 
signs of cardiac disease. In children, cases with a slight or marked 
valvular lesion which are apparently at a standstill, give certain 
symptoms which are significant of defective cardiac action. On ex- 
ertion, the children complain of pain in the side or the epigastrium. 
Examination will show little change in the cardiac areas. The 
valvular murmur is heard. Such hearts are also irritable. I have 
often found a distinct history of palpitation occurring at intervals 
and even in the absence of exertion. Many children with chronic 



652 



DISEASES OF THE CIRCULATORY SYSTEM. 



cardiac disease of a very mild and absolutely quiescent type, exhibit 
a persistent pallor which does not yield to drugs. Children without 
other symptoms complain of headaches after slight excitement. Ex- 
amination will, in these cases also, show a slight hitherto unrecog- 
nized chronic cardiac valvulitis. Slight oedema of the eyes which is 
persistent should direct attention to the heart. 

Fig. 144. 




Chronic cardiac disease ; dilatation of the right and left ventricles. Epigastric pulsation. 

Boy, six years of age. 

Many cases without any other signs of chronic cardiac disease 
show a slight evanescent trace of albumin in the urine. 

There may be absolutely no signs of cardiac insufficiency or 
change in the physical character of the organ. Children with signs 
of quiescent cardiac disease often have obscure attacks of faintness 
and vomiting, following every little excitement. 

There are also the rheumatic recurrent cases of endocarditis in 



CHRONIC VALVULAR DISEASE OF THE HEART, 653 

childhood. These exhibit very much the same symptoms of cardiac 
insufficiency as the corresponding cases in adults, viz., enlarge- 
ment of the liver and spleen. Children appear to recuperate 
more rapidly than adults, but, on the other hand, the attacks are 
more likely to recur in them than in older subjects. A compro- 
mised heart in a child will bear more strain than in an adult. Cases 
are frequently seen in which children show on physical examina- 
tion marked chronic disease, but are notwithstanding exceedingly 
active and show no symptoms referable to the heart. The signs of 
insufficiency of the cardiac muscle are the same in children as in the 
adult. There is dyspnoea on exertion, slight oedema of the general 
surface, and enlargement of the liver and spleen. In the later stages, 
there are transudates in the pleura and abdomen. In some cases, es- 
pecially where there is progressive interstitial myocarditis with 
adherent pericardium, the pleura may show unilateral transudate. 

In cases of cardiac insufficiency, the pulse is persistently high or 
very irregular. There is persistent dyspnoea. Children with cardiac 
disease suffer, as a rule, less than adult subjects. 

Cardiac angina is not an uncommon symptom in cases of aortic 
disease. It is present in cases in which there are signs of lack of 
compensation. The angina comes on in attacks occurring chiefly at 
night, and is very severe. I have seen a boy of eight years with an 
aortic murmur suffer from these attacks for days. In such cases there 
are a dilated ventricle and an enlargement of the liver and spleen. 

The prognosis of chronic valvular disease in childhood depends 
very much on the type of disease. If the heart is only slightly 
affected and the patient not a rheumatic subject, the outlook is good. 
With careful management all ill after-effects can be avoided ; chil- 
dren thus affected may grow to adult life without suffering from any 
symptoms referable to the heart. If, on the other hand, they are 
attacked by any intercurrent disease, such as scarlet fever, the heart 
may again become the seat of inflammatory processes. The patients 
may, however, recover and continue free from symptoms for years. 
The rheumatic cases give the most unfavorable prognosis. These 
are prone to recurrent attacks of endocarditis, each attack leaving 
the heart in a more weakened condition than before. Most of my 
cases have been in children who, having had one attack of rheu- 
matic endocarditis, suffered from the affection to a greater or lesser 
degree for years. Within a few years of the first attack they succumb 
to progressive non-compensatory cardiac disease. 

Treatment. — Many cases of cardiac disease in infancy and child- 
hood give no symptoms and need very little treatment beyond careful 
and judicious management. Children thus affected should have a 
carefully regulated dietary, ^nd should not indulge in sports which 
subject the heart to strain. They should not ride the bicycle, but 
may, however, indulge in many of the amusements of children, 



654 DISEASES OF THE CIRCULATORY SYSTEM. 

such as skating, roller skating, swimming to a moderate degree, and 
horseback exercise. They should be under constant observation, and 
when attacked by any acute infection liowever slight should be put 
to bed, and kept quiet until long after convalescence. In these cases 
an antirheumatic course is pursued even although the illness be only 
a mild attack of influenza or tonsillitis. It is well to give the sali- 
cylates in small doses for several days and to keep the bowels open 
with some alkaline cathartic. With children who suifer from rheu- 
matism, the nature of the primary disease should not be forgotten. 
They should have constant antirheumatic treatment even when the 
cardiac disease is at a standstill. Heinian has recently shown the 
beneficial effects of the intermittent administration of salicylates in 
these cases. I have carried out that method for some time. Alkaline 
baths of the Nauheim form are of great utility in alleviating the 
subacute rheumatic pains from which these subjects suffei', and this 
treatment also tends to keej) the rheumatic tendency in abeyance. 
Such children should be kept under constant observation. The tem- 
perature should be taken twice daily. Any rise of temperature should 
be regarded as a threatening sign and the j^atients put to bed for 
perfect rest until the crisis has passed. In cases in which there is 
marked dilatation or pericardial involvement, any exacerbation of 
symptoms is a signal for immediate rest in bed. Slight (rdema of 
the surface and swelling of the liver and spleen will subside if 
treated with perfect rest, a light assimilable diet (milk), and mild 
alkaline catharsis. It is not always necessary to use digitalis. If 
given at all, it is best administered in the form of the infusion. 
I am accustomed to use this drug for a period of two or three days, 
after which I discontinue it. There is no doubt that its action con- 
tinues after the administration is stopped. Convallaria in the form 
of the fluid extract is at times one of the most useful remedies in 
cases in which digitalis has failed to give relief. If there is great 
dyspnoea or orthopnoea, codeine in moderate doses should be used. 
Young children d(^ not bear morphine well. It certainly should 
not be used hypodermatically. In aortic disease in older chil- 
dren, nitroglycerin in doses of grain -j-^-q (0.0006) relieves the 
angina. I administer morphine only to older children, and then 
only when the nocturnal attacks of angina are very severe. I have 
not found strychnine very useful in the chronic forms of cardiac 
disease. Caffeine in moderate dosage seems more useful in correcting 
the irregularity of the pulse or bradycardia seen in some of these 
cases. In combination with digitalis it gives excellent results. If 
ascites appears, the patient should be promptly tapped to relieve the 
circulation and the abdomen supported by a binder. If there is a 
pleuritic effusion at the same time, it should not be disturbed. With 
relief of the abdominal distention, the pleuritic effusion often dis- 
appears. 



CARDIAC MURMURS IN INFANCY AND CHILDHOOD. 655 



Cardiac Murmurs. 

Cardiac murmi^rs which are the result of disease or insufficiency 
of the valves of the heart have the same general character as those 
in adults, the following being the chief points of difference : 

a. Cardiac disease of a very serious character may exist (as in 
congenital cyanosis) without any murmur. 

b. Cardiac murmurs are as a rule louder in children than in adults. 
The loudness is therefore no guide as to the seriousness of the affection. 

c. Cardiac murmurs in children are sometimes heard loudly 
conducted over the whole chest ; diagnosis of disease of a particular 
valve must be based on the greatest intensity of the murmur at that 
point. 

d. Hsemic and dynamic murmurs in children under four years of 
age are not so common as is supposed. There should be no hesitation 
in making the diagnosis of organic affections in systolic, basic, or 
apex murmurs if there are distinct conduction or signs of dilatation 
or hypertrophy. This is especially to be remembered in chorea, 
extreme anaemia, and in febrile affections where rapidity in time and 
rhythm (galloprhythms) causes adventitious sounds. 

e. The conduction of the aortic murmurs into the arteria femoralis 
occurs in occasional cases in children. Pulsation of the liver or 
spleen, as found in aortic disease of adults, is not present in children 
(Steffen). 

Accidental Cardie Murmurs in Infancy and Childhood. 

Accidental murmurs are divided into those heard over the heart, 
in the arteries, and in the veins. The study of the accidental murmur 
of the heart in infancy and childhood has been much neglected. 
West and Hochsinger give the most valuable data. The principal 
points of difference between the murmurs in infants and children 
and those in the adult are as follows : 

Cardiac Murmurs. — Ancemia. — The severest forms of anaemia 
sometimes fail to give hsemic murmurs. Not one of 200 cases under 
four years of age examined by Hochsinger gave anaemic murmurs. 
After the fourth year and up to the seventh year of life the fre- 
quency of the anaemic and haemic murmurs increases. I have in 
very exceptional pernicious anaemias found a mild blowing basic 
murmur. One such case occurred in a child under four years. 

Fevers. — The haemic murmurs so common in the febrile affections 
of adult life are rarely heard even in severe febrile affections w^ith 
anaemia, in patients under the age of three years. I have heard 
them in children under three years of age, with severe typhoid fever. 
They are common in typhoid fever in older children. 



656 DISEASES OF THE CIRCULATORY SYSTEM. 

Characteristics of Ancemia Murmurs. — These never occur with 
signs of cardiac dilatation or hypertrophy. They are not conducted 
into the arteries. They never entirely take the place of the valvular 
cardiac sounds, but accompany them. They are soft blowing 
murmurs, heard at times most loudly at the pulmonary valve, some- 
times heard over the base and whole prsecordium, and faintly 
heard at the apex. They are never heard at the aortic or tri- 
cuspid valves, or behind. They are inconstant, disappearing for a 
time and again appearing at the various points of the chest. 

Accidental Arterial Murmurs. — The theory held by some 
observers, that pressure of the stethoscope on the arteries of the 
neck may cause a murmur, should be entertained with caution. Cor- 
rect stethoscopy wdll hardly lead to such an error. A murmur in 
the large arteries of the neck is conducted from the heart and is 
invariably organic in origin. I have heard aortic murmurs con- 
ducted in the femoral artery. 

Venous Hum. — Although cardiac accidental murmurs due to 
anaemia are rarely heard in children, the venous hum due to the 
same cause is frequently heard. In young infants and children it is 
present in the veins of the neck, is quite loud, and is heard at either 
side of the upper part of the sternum. If there is anaemia due to 
valvular cardiac disease, the venous hum is heard in the arteries of 
the neck, with the organic murmur. 



Myocarditis. 

Myocarditis is very frequent in infancy and childhood. Most 
of the knowledge of this condition has been obtained from a study 
of the disease in young subjects. This is due to the fact that in 
early life the heart is especially exjiosed to the deleterious action of 
the toxins of the infectious diseases. Myocarditis is a degeneration 
or inflammation of the muscular substance of the heart, secondary to 
the action of poisons (phosphorus) to the toxins of bacteria (as in 
the exanthemata, typhoid fever, diphtheria, pertussis, sepsis, osteo- 
myelitis), or to the changes consequent upon disease of the peri- 
cardium, or endocardium, of rheumatic or infectious origin. 

Morbid Anatomy. — If there is degeneration of the myocardium, 
only the muscular fibre may be the seat of fatty changes. There 
is an increase of fat drops in the muscular tissue of the heart. In 
advanced conditions, the fatty changes are apparent to the naked eye 
as a yellowish discoloration beneath the endocardium. In other cases, 
there is a granular or hyaline degeneration of the muscle fibre or 
a vacuole formation. The cell protoplasm becomes cloudy, hyaline, 
loses its striation, and disintegrates or is replaced by drops of fluid. 
This occurs in diphtheria, typhoid fever, pneumonia, chronic con^ 



MYOCARDITIS. 657 

gestion, and in toxaemia of various kinds. Thrombi may form in 
hearts which are the seat of advanced degeneration. In toxaemia 
and the infectious diseases, there is inflammation of the myocardium. 
There is an invasion of the muscle tissue by bacteria from the endo- 
cardium (staphylococci, streptococci, and pneumococci). In such 
cases, there are also grayish or yellowish discoloration of the muscle 
tissue, vacuolization, and granular and hyaline degeneration. The 
muscle tissue is the seat of small cell infiltration or there may be 
abscesses of microscopic or macroscopic size. If recovery occurs 
these areas may cicatrize with connective tissue. Tuberculous 
and syphilitic inflammations of the myocardium occur, but are 
uncommon. 

Etiology. — The degenerative or inflammatory changes may be 
caused by the direct action of the bacteria (Almquist), but usually 
the influence of the bacteria themselves is only slight, since they do 
not find in the myocardium a favorable soil for growth. The toxins 
of these bacteria produced either elsewhere in the economy and 
circulating in the blood, or in the heart muscle itself, are chiefly 
instrumental in causing the degenerative changes (Welch, Flexner, 
Schamshin). Fever, as such, has only a slight influence in caus- 
ing myocarditis (Werhofsky). 

The symptoms of myocarditis can best be understood by study- 
ing the heart in the various infectious diseases. In diphtheria, 
myocarditis may be suspected if there occur sudden syncope, faint- 
ness, chilly sensations, vertigo, and vomiting. The patients com- 
plain of praecordial weakness ; there are all the symptoms of collapse 
and a flickering, irregular pulse. These phenomena may appear at 
intervals throughout the disease and persist far into convalescence. 
In this disease there is during convalescence an irregularity of the 
heart apparent in the rhythm and force. There will be two or three 
beats and then an interval, followed by two or three beats. The 
pulse at the wrist may be of varying compressibility. In these 
cases there may be no other manifestation of the eflect of the poison 
of the disease on the heart-muscle and ganglia. There is no pain, 
no vomiting, no praecordial distress, yet for days the heart-action 
will remain irregular and cause great uneasiness to the physician. 
Such cases may make a good recovery. In some exceptional 
cases, however, these symptoms precede more serious disturbances 
of a severe and even fatal character. The forms of marked cardiac 
irregularity are especially disquieting if observed during or after 
diphtheria, even of a mild type. In these cases the physician is 
ill at ease on account of the well-known occurrence of sudden 
death in this disease. I have seen irregularity persist in these cases 
for weeks, to disappear finally ; and yet during all this time the 
physician can give no positive assurance that the case may not result 
fatally. Simple irregularity, as a rule, without signs of true mus- 
42 



658 DISEASES OF THE CIRCULATORY SYSTEM. 

cular weakness of the heart, such as swelling of the liver or dilata- 
tion of the ventricle, retrogrades to the normal. 

In acute forms of pneumonia in which the toxaemia is very great, 
infants may, even at the outset, exhibit cardiac weakness. There are 
slight cyanosis of the lips and abnormal pallor of the face and gen- 
eral surface. The heart action is more rapid than in other cases of 
pneumonia in which the lung lesion is quite as extensive. At the 
crisis, the action of the poison on the heart is evinced by an irregu- 
larity or arhythmia of the pulse. The pulse may be extremely slow 
(bradycardia). In septic conditions there will, late in the disease, be 
galloprhythm, distortion of the pulse-respiration ratio, cyanosis, 
and extreme prsecordial distress. Henoch, Osier, and I have shown 
that there may be degenerative changes in pertussis. These are clini- 
cally apparent in cases which have extended over a long period. A 
constant dyspnoea, an abnormally high pulse-rate, drowsiness, dis- 
inclination to exertion, and slight oedema of the face and other parts 
of the body are present. In rare cases physical examination reveals 
a slight dilatation of the right ventricle. In other cases there is 
at the apex a faint systolic murmur of purely muscular origin. In 
adherent pericardium, the advance of the process into the myocar- 
dium is indicated by the symptoms above detailed. 

The myocarditis of chronic valvular disease is a progressive 
process. It manifests itself by the signs of lack of compensation de- 
scribed in the section on Chronic Valvular Disease. The varying 
pulse, the dyspnoea, the enlargement of the liver and spleen, and 
transudates into the serous cavities, all indicate this form of pro- 
gressive weakness of the cardiac muscle. 

Diagnosis. — Although the diagnosis cannot in all cases be made 
with absolute certainty, the presence of the condition may be sus- 
pected if the following sets of symptoms appear at regular intervals 
in the course of the disease — attacks of palpitation and faintness, 
pallor, cardiac irregularity, galloprhythm and weakness of the apex 
beat and of the first muscular sound of the heart, with intensifica- 
tion of the second pulmonic sound. 

The treatment should support the heart and lessen its work, and 
should also be directed toward the management of the primary 
condition. In all of these cases, prolonged rest for the heart, con- 
tinued long after convalescence, is of primary importance. It 
should not be forgotten that even in a degenerated organ there 
is healthy tissue on which the drugs and treatment act. These 
healthy foci should be sustained, and not exhausted by the action 
of powerful drugs given in large doses. Degeneration cannot be 
cured by drugs ; nature must heal the diseased areas. 

Cardiac irregularity pure and simple, with a pulse of moderate 
slowness, is best treated by means of strychnia and caffeine. To a 
child of three or four years of age, strychnia, y^^ grain, is girsn 



HYPERTROPHY AND DILATATION OF THE HEART. 659 

with or without a grain of caffeine every three hours. Warmth is 
applied to the heart, and if the extremities are cold, warm bottles 
are applied also. Camphor is a very excellent remedy, but can 
only be used for a short length of time, for it is badly borne by 
the stomach, and in such cases must be used hypodermically. Oil 
of camphor, 30 minims, may be given to a child three years of age. 
Severe cases accompanied by a galloprhythm are treated with digi- 
talis. This drug is an excellent remedy in these cases, but must be 
used cautiously, in small doses. To a child of three or four years 
of age, TTLij of the tincture of digitalis given every three hours is 
sufficient. If restlessness or vomiting appear, morphia is our only 
safeguard, but should be used cautiously. Enough only is given to 
quiet the patient. One or two minims of Magendie^s solution is 
given to a child three to five years of age, by the mouth. 

Hypertrophy and Dilatation of the Heart. 

Cardiac hypertrophy and dilatation, combined or singly, and with- 
out any valvular lesion, occur in isolated cases in childhood. The 
condition is rare before the fifth year. A number of cases occurring 
between the fifth and the tenth year have been reported. If hyper- 
trophy alone is present, it may affect the left ventricle only, or both 
ventricles. Dilatation usually afPects first the right ventricle and 
then the left. The condition develops as a result of toxsemic influ- 
ences, in the acute infectious diseases, such as scarlet fever, pneumonia, 
diphtheria, and typhoid fever. 

Hypertrophy with or without dilatation is one of the sequelae of 
acute or chronic nephritis. The nephritis complicating scarlet fever 
is frequently the cause of cardiac hypertrophy with or without dila- 
tation. Atheromatous conditions of the arterial system with dimi- 
nution of the calibre of the aorta may cause hypertrophy with or 
without dilatation. Acute dilatation as a result of heart strain is 
unknown in children. 

The symptoms are not characteristic. In the absence of all 
other heart lesions, the diagnosis of cardiac hypertrophy or dila- 
tation is made from the physical signs. These do not differ from 
those found in the adult subject. The rational symptoms also resemble 
those of the adult. In dilatation of the heart, there are the irregu- 
lar heart action, the dyspnoea or orthopnoea, the pallor of the surface, 
cyanosis, and in the later stages swelling of the liver and spleen. 
Transudates in the pleural and abdominal cavities are apt to occur 
toward the close. Sudden death has occurred in some cases of dila- 
tation of the acute variety. In hypertrophy, the symptoms closely 
resemble those just detailed. At the bedside, the diagnosis of hyper- 
trophy, of dilatation, or of both, must of necessity rest on the physical 
signs. 



660 DISEASES OF THE CIRCULATORY SYSTEM, 

The treatment varies with the nature of the primary disease 
(nephritis or toxaemia) present. Tiie nephritis should be treated 
and the heart will take care of itself. If there is an infectious dis- 
ease, such as typhoid fever, diphtheria, or scarlet fever, both the 
heart and the primary affection should be treated. 

Eeferences of Authorities for Collateral Keading. 

Ausset, E. : Maladies des Enfants, 1898. 

Fkischman, L. : Klinik der Piidiatrik, 1875. 

Gutimann, P. : Untersuchungs Methoden, 1886. 

Henschen, S. E. : Ac. Herzdilatation, Jena, 1899. 

Heubner, 0. : " Ueber Chorea," Verhandl. d. gesellschaft der Kinderazte, Ham- 
burg, 1901. 

Hochsinger, Carl: Auscultation des Kindliclien Herzens, Wien, 1890. 

Jurgensen, T.: ** Endocarditis," Notlinagel's Spec. Path., 1900. 

Jacobi, A. : " Functional and Organic Heart Murmurs," Med. News, 1900. 

; "Acute Rheumatism in Infancy and Childhood," Amer. Clin. Lectures, 

1879. 

Keating and Edwards: " The Pulse in Childhood," Archives of Pediatrics, 1888. 

Musser, J. H.: "On the Disappearance of Endocardial Murmurs," Brit. Med. 
Jour., 1897. 

Mendolsohn, M: " Der Einfluss des Radfahreus, Berlin, 1896. 

Packard, F. A. : N. Y. Med. Jour., June, 1899. 

Sahli, H. : Topographische Percussion, Bern, 1882. 

SoUmann: Herzgerausche im Kinderalter. 14te Verhandl. gesell. Kinderazte, 
1897. 

Sansom, A. E. : Diagnosis of Diseases of the Heart, London, 1892. 

Ullman, J. : " The Tonsils as Portals of Infection, with Literature," Medical 
News, 1900. 

Vierordt, H. : " Die Augeborenen Herzkrankheiten," Nothnagel's Spec. Path., 
etc., 1898. 

Walshe: Diseases of the Heart, London, 1873. 

Weill, E. : Maladies du Coeur des Enfants, Paris, 1895. 



SECTION VIII. 

CONSTITUTIONAL DISEASES. 
I. RACHITIS. 

{Rickets.) 

Rachitis is a disease of nutrition causing well-marked changes 
in the structure and form of the growing bones. It is peculiar to 
infancy and childhood, and does not occur after the skeleton is 
formed. 

Etiology. — There are two forms of rachitis, the congenital or 
foetal and the post-natal. 

The occurrence of congenital, foetal, or intra-uterine rachitis is 
still a subject of much difference of opinion. According to some 
authorities (Kassowitz), 80 per cent, of the infants of the Vienna 
Maternity Hospital show evidences of rachitis. Epstein at one 
time demonstrated the great frequency of rachitic deformity at the 
costochondral junction of the ribs, in the infants of the Maternity 
Hospital in Prague. 

Congenital Rachitis. — There can be no doubt of the existence of 
such a condition as rachitis in utero, or congenital rachitis. In these 
cases the infant at birth has craniotabes, or, if closely examined, the 
rosary and other marks of the true rachitic process on the long bones 
may easily be made out. We must not confound such cases with 
what has been called foetal rickets. The latter term, as will be seen, 
has been practically abandoned, and was at one time applied to cases 
of ch oudrody strop hia. It is not at all a rachitic process, and has 
nothing in common with rachitis. Virchow insists that foetal rachitis 
in the true sense is rare, and that an anomaly in the development of 
the primordial cartilage has been mistaken for rachitis, with which it 
has nothing in common. 

Hemorrhagic rachitis is a term applied by some authors to Bar- 
low's disease or infantile scurvy. Rachitis is for the most part 
post-natal, and its onset occurs most frequently during the first year 
of life. It is rare after the third year. The sexes are equally subject 
to the disease. A moist climate favors it. It is very common in 

661 



662 CONSTITUTIONAL DISEASES. 

Germany and Austria, and is rarely met in southern Asia or Central 
America. Fischl insists that it is peculiar to some races of people, 
and Snow, of Buffalo, has shown that Italians living in America, 
are peculiarly subject to it. It is most common among civilized 
communities, in which infants, especially those of large cities, are 
fed upon substitutes for breast milk. On the other hand, breast- 
fed infants may develop rachitis, but in such cases investiga- 
tion of the milk by Pfeilier and others has not resulted in the dis- 
covery of any peculiarity of the milk which might be looked upon 
as a causative factor. Rachitis develops in infants who have been 
weaned from the breast early and fed on artificial foods or sterilized 
milk. The early introduction of meats and solid food into the 
dietary of the infant has been cited as an etiological factor. 

That syphilis is a direct causative agent in rachitis (Parrot) can 
no longer be accepted. Heredity does not seem to exert any influ- 
ence. There are many theories as to the active and immediate 
causes. The principal theories are those which presuppose the lack 
of some element, such as phosphates or lime salts, in the food, and 
those that trace the processes of rachitis to a disturbance of nutritive 
functions caused by an increase of certain acids (lactic) in the 
stomach, a diminution of others (hydrochloric) and resulting intes- 
tinal functional irregularities (Monti, Zander). The intestinal dis- 
turbances cause the elimination of certain salts from food, hence the 
blood fails to receive what is necessary for the structure and forma- 
tion of the bones. 

Morbid Anatomy. — Rachitis is anatomically characterized by 
processes which cause an increased resorption of bone, deficient calci- 
fication of cartilage, and the formation of a characteristic tissue — a 
deficiently calcified bone, the so-called osteoid tissue (Ziegler, Kasso- 
witz, Schmorl). The increased resorption consists in an augmenta- 
tion of the number of areas of lacunar absorption. In marked 
rachitis the greater part of the bony skeleton is lost. The cortical 
area of the long and of the short bones becomes osteoporous. A 
large part of the lamellae of the cancellous bone is absorbed and dis- 
appears. In the flat bones the arrangement of outer and inner table 
separated by the intervening diploe is lost. The bone tissue is re- 
duced to a few lamellae. At the zones of periosteal and medullary 
ossification, the lamellae are replaced by osteoid tissue. This tissue 
is a new formation devoid of lime salts. 

The marrow of the osteoid tissue formed from the periosteum or 
medullary canal consists of a reticulum of striated connective tissue 
rich in bloodvessels and enclosing free round cells. Beneath the 
periosteum of the cranial and long bones there is formed, because of 
these changes, a spongy vascular tissue which is resistant to pressure 
and may be cut with a knife. While the rachitic process lasts, no 



RACHITIS. 663 

lime salts appear in the lamellse of osteoid tissue, but as soon as the 
disease has spent itself those salts appear in the centre of the lamellae. 
Complete recovery results in calcification of these lamellse, which 
being proliferated leave the bone hardened and very much thickened. 
The pathological change in the endochondral ossification consists in 
an entire absence of a calcification zone. In severe rachitis, all 
signs of the deposit of lime salts are absent. There is a widening 
of the zone of proliferation of cartilage cells, and also of the columns 
of hypertrophoid cartilage cells. There is lastly an irregular forma- 
tion of vascular marrow-spaces, which grow here and there into the 
cartilage from the bone. Thus at the junction of cartilage and bone, 
there is in the long bones no distinct line of ossification. The red 
marrow-spaces extend for varying distances into the cartilage. 

The abundant growth of bloodvessels extending from the peri- 
chondrium into the cartilage is accompanied by the substitution of 
osteoid tissue and marrow-spaces for the cartilage proper, as in 
periosteal and medullary ossifications. In rachitis the cartilage is 
never completely absorbed by osteoid tissue. Thus, on section, the 
bone shows, nearest the cartilage, the zone of proliferating cartilage- 
cells with hypertrophied cells in columns ; next to this is the zone 
of osteoid tissue in lamellae in which few lime salts are deposited. 
Kearer the bone are lamellae of osteoid tissue, in the centre of which 
fully formed bone is deposited. The lamellae of osteoid tissue differ 
from those of normal bone in being much thicker and more abun- 
dant. The osteoid tissue is very resilient and easily bent, hence this 
property of rachitic bones. The process leaves the bones much 
thickened, especially at the epiphyseal extremities. The deformities 
of the chest, extremities, pelvis, and spine can thus be traced to 
the tendency of the rachitic bone to bend on pressure and traction. 
The effects of the process on the shape of the cranium and the 
delay in the formation of the teeth may thus be easily accounted for. 

Among other gross lesions connected with the clinical picture 
of rachitis is enlargement of the spleen. The organ may be very 
large and easily palpated below the border of the ribs. Sasuchin 
found that of 66 cases of rachitis, the spleen was enlarged in 12 to 
15 per cent. The changes in the organ consisted in thickening of 
the capsule and proliferation of the connective tissue of the organ, 
arteritis, thickening of the walls of the arteries, atrophy and obliter- 
ation of the Malpighian bodies, and anaemia of the organ. This 
important blood-distributing organ is thus compromised. The 
spleen may be increased to two and a half times its normal size. 
The liver may also be apparently enlarged. During life the enlarge- 
ment of the liver may be more apparant than real. The chest, if 
narrow and deformed, may cause downward displacement and rota- 
tion of that organ. In rachitic infants the lymph-nodes are more 



664 CONSTITUTIONAL DISEASES. 

apparent on palpation than is normal. They, however, are never 
increased to the size attained in tuberculosis, syphilis, or eruptions 
of the skin, such as those of the exanthemata. The blood may show 
the changes of extreme simple anaemia — an increase in the nucleated 
red blood-cells and other signs. 

Brain. — Slight or marked hydrocephalus is frequently found in 
rachitis. The relation between the two conditions is not clear. If 
the infant dies of an intercurrent disease, changes of a chronic 
catarrhal character may be found in the gut and signs of bronchitis 
or persistent bronchopneumonia in the lungs. These conditions follow 
the changes in nutrition Avhich cause the rachitic processes elsewhere. 

Symptoms. — The most marked and general symptoms of 
rachitis are changes in the bony skeleton. 

The Head. — The shape of the rachitic head is very characteristic. 
The frontal bone bulges, giving the infant a very promiuent fore- 
head. The parietal bones have a flare, caused by the formation of 
bosses at the centres of ossification. The whole head has a cuboidal 
shape, which, with the proportionately small face, gives the character- 
istic appearance. The disturbances in bone formation cause the appear- 
ance of soft spots, especially in the vicinity of the lambdoidal suture. 
These (craniotabes) may be membranous iu structure. They rarely 
appear on the frontal boues in the vicinity of the coronary suture. 
The spots of craniotabes appear in infants who develop rachitis before 
the sixth month (Monti), rarely after this period. They take four or 
five weeks to develo}) fully. In developed rachitis the occiput is flat 
and devoid of hair (Plate XIX.). The anterior fontanelle,^ which 
normally closes between the fifteenth and the eighteenth month, 
remains open for a long time, in some cases until the third or fourth 
year, or even to the sixth. The sutures are also slow in closing. The 
coronary sutures may remain open for two, and the longitudinal 
suture for three years. The lambdoidal suture does not in some cases 
close until the eighteenth month. 

If the thorax is affected by rachitis, the circumference of the head 
will exceed that of the chest. The lower jaw has an angular deformity, 
described by Fleischmann. This consists in a bending of the body 
of the jaw at the situation of the canine teeth. The body of the 
jaw is also rotated internally on its horizontal axis. If rachitis 
begins before the sixth month, dentition is delayed for periods 
varying up to a year and a half. I have a record of a case in which 
the first tooth appeared at the twenty-fourth month. If rachitis 
develops after appearance of the first teeth, the succeeding ones appear 

^ While tlie lateral and posterior fontanelles close durino: the first montlis of 
infancy, the anterior fontanelle increases in its longitudinal and transverse diameter 
with tlie growth of the cranium up to the twelfth month. The growth of the 
anterior fontanelle was first observed by Elsasser. Alhough denied by Kas- 
sowitz it has been recently proved by Rhode that the contention of Elsasser is 
correct. 



PLATE XIX. 




Rachitis. Showing the euboidal shape of the head, the 
thoracic deformity, the beaded ribs, the protuberant abdo- 
men, and the enlarged lower end of the radius. 



RACHITIS. 



665 



later than is normal. The structure of the teeth suffers. They 
show erosions, are easily broken, and become carious quickly. This 
is due to imperfect formation of enamel or dentine. Some time after 
their eruption, the incisors show a well-marked incurvation at the 
free border, which is due to erosion or breaking of the tooth. 

The thorax shows very characteristic deformities. Rachitis of 
the thorax in most cases develops in the second half year, and may 



Fig. 145. 




Rachitic deformity of the spine. Uniform curvature backward. 

continue into the third year. The first marked sign is the appear- 
ance of the so-called rib rosary. This is a thickening of the costo- 
chondral junction of the rib, in which the rachitic processes above 
described are very active. Deformity of the thorax follows in course 
of time. The thorax becomes prominent at the sternum and flat- 
tened in the midaxillary region from the axilla to the free border of 
th'o ribs. There is a distinct incurvation of the thorax above, and a 
flaring below. The thorax is much narrowed at the clavicles, with 
a flaring outward of the lower ribs. Respiration, especially inspira- 



666 



CONSTITUTIONAL DISEASES. 



tion, is much interfered with. The sides of the thorax are drawn 
inward at the diaphragm at each inspiration. In an attack of 
severe bronchitis or bronchopneumonia, the drawing inward of the 
sides of the chest becomes still more marked. In some cases the 

Fig. 146. 




Angular deformity of the spine, due to Pott's disease, as distinguished from the deformity 

due to rachitis. 



sternum alone is affected. There is a sinking of the sternum, with 
resulting chest deformity. Some forms of rachitis affect only the 
ribs or part of the thorax. While the rachitic process is in 
progress, the chest circumference does not increase ; it begins to do 
so when the disease has run its course in the thorax. 



RACHITIS. 667 

Pain. — When the infant is raised from the chair or crib, it 
cries. This is the result of the painful nature of the rachitic process 
in the bones. Forcible percussion of the chest will cause pain. On 
account of the deformity of the chest and the consequent interference 
with its physiological functions, the lung is prone to contract in- 
fections, such as bronchitis and bronchopneumonia. Atelectasis is 
also a common complication. The clavicle becomes bent and frac- 
tures on the slightest traumatism. At the termination of the rachitic 
process, the clavicle and scapulae are much thickened. Virchow 
has shown that the scapula becomes the seat of an angular deformity. 

Spine. — On account of the relaxation of the ligaments of the bodies 
of the vertebrae and of the rachitic processes in the bodies of the 
bones themselves, there is in most rachitic infants a bending backward 
of the dorsolumbar spine (Fig. 145). The curvature is very marked 
when the infants are held in the arms. It differs from deformity 
due to Pott's disease in that it is not angular, and in that the spine 
can be straightened and even curved forward with ease (Fig. 146). 

Lateral curvatures of the spine are also found. If the spinal 
deforniities occur early in infancy, they disappear as the rachitis heals 
and the ligaments and muscles regain a normal tonicity. On the other 
hand, should' the rachitic process attack the spine late in the third or 
fourth year, the deformities are perpetuated. This is especially the 
case if the pelvis is also affected at that time (Monti). 

The pelvic deformities which result from rachitis are chiefly flat- 
tening of the pelvis, and the pseudo-osteomalachic pelvis. 

Upper Extremities. — The epiphyses are much swollen and, in rare 
cases, painful. The wrist is flat and much broadened. If the 
rachitis is elsewhere not marked, the physician should be careful not 
to mistake a normal enlargement in this situation for rachitis. In 
exceptional cases, the elbow and shoulder-joint show similar changes. 

On account of the traction of the flexors and pronators, the fore- 
arm may be incurvated and the bones twisted on their longitudinal 
axes. The result is a more or less fixed position of pronation in the 
forearm. The arm is rarely curved in this manner, but it may, like 
the clavicle, be fractured after slight traumatism. As a result of 
rachitis and deformity, the growth of the bone in length is much 
interfered with. 

The phalanges are sometimes the seat of the rachitic processes. In 
some severe cases I found all the phalanges thickened in the diaphy- 
ses. These cases bear a very close resemblance to dactylitis syphilitica, 
especially as there is pain on pressure (Fig. 147). 

The deformities of the lower extremities are more marked than 
those of the upper ones. On account of the pain experienced, the 
infants refuse to stand ; they will draw the extremities up under- 
neath the abdomen, if any effort is made to make them do so. In 
other cases, when attempts are made to stand, the weight of the 



668 CONSTITUTIONAL DISEASES. 

body and the muscular traction (Kassowitz) cause deformity. The 
femur, tibiae, and fibulae curve outward, giving the so-called ^' bow- 
leg" deformity (Plate XX.). This may in extreme cases result 
in a deformity of the heads of the bones entering into the forma- 
tion of the knee-joint. The ankle-joint may suifer a varus de- 
formity. The femur and tibiae may curve inward, and a knock- 

FiG. 147. 



Rachitic hands, showing bowing and thickening phalanges of fingers (author's case). 

knee deformity result. In all cases, there is relaxation of the liga- 
mentous joint-structure. The tibia sometimes becomes much thick- 
ened and curves anteriorly, giving the so-called " sabre deformity.'^ 
It may be twisted on its longitudinal axis. I have seen severe 
rachitis of the femur and tibia result in multiple fractures. 

The deformity at the hip-joint, which later in life follows changes 
in the angle made by the neck of the bone with the shaft of the 
femur (coxa vara), is believed to be due (Whitman) to rachitis. The 
children are late in walking. The musculature is weakened through 
disuse. 

When the children assume the sitting posture, they cross the lower 
extremities in tailor fashion. In the majority of cases of rachitis, the 
abdomen is protuberant. As a result of the defective nutrition, 
the musculature of the gut is weakened in the same manner as 
that of the extremities. Tympanitic distention is the rule. 

Intestinal disturbances are common in rachitis, but are not a 
result of the process. Henoch shows that rachitis may be present 
with an apparently normally functionating intestine. 



PLATE XX 




Rachitis. Showing the deformity of the thorax and 
marked bo^A^ing of the tibiae. 



RACHITIS. 669 

The spleen is enlarged in many cases of rachitis, but retrogrades 
to the normal size after the disease has run its course. 

The blood shows the changes found in ordinary mild or severe 
simple anaemia. 

The liver may be slightly enlarged. 

Ansemia of the skin and mucous membranes is frequently found. 
It may be so extreme as to cause the skin to have a yellowish 
waxy hue. Rachitic children perspire freely at night, especially 
about the head. Unless the skin is kept scrupulously clean, 
sudamina, furuncles, and eczema of all kinds will result. 

Nervous System. — There is no doubt that certain nervous affections, 
such as tetany, laryngismus stridulus, attacks of inspiratory apnoea, 
spasmus nutans, and the so-called barn-yard crowing or congenital 
stridor of the larynx (described by Thomson), occur most frequently 
in subjects of rachitis. Some authors (Kassowitz, Jacobi, Escherich) 
trace a distinct etiological connection between these conditions of 
instability of the nervous system and rachitis. 

Hydrocephalus occurs in rachitic subjects. In cases of severe 
rachitis, an appearance of mild hydrocephalus is given to the face 
by a downward depression of the eyeball. The sclera of the eyes 
is thus slightly exposed. The appearance seems to be caused by 
a depression of the orbital plates of the frontal bone by the over- 
lying frontal lobes of the cerebrum. In many cases of severe rachitis, 
the wide fontanelle, its tenseness, and the open coronal and temporal 
sutures give a picture like that of a non-progressive, mild hydro- 
cephalus which is simply a feature of the nutritive disturbances 
taking place in the brain as elsewhere. 

Severity of the Affection. — These symptoms are not present in 
all cases of rachitis. In some cases there are only very slight signs 
of the disease, such as a slightly cuboidal shape of the head or a 
scarcely appreciable bending of the ribs without any deformity. In 
such cases even an expert may be in doubt as to the presence of 
swelling of the epiphyses. In other cases an intercurrent affection, 
such as tetany, will cause the physician to seek for signs of rachi- 
tis, which may be so slight as to have previously escaped notice. 
Craniotabes is sometimes absent in marked cases. Delayed denti- 
tion is not the rule. Rachitis may be very evident in cases in which 
the teeth appear in their normal order. 

Duration. — In such a disease as rachitis it is to be expected that 
the duration of the affection will vary greatly in different subjects ; 
it may last months in some cases, in others years. The first favorable 
sign is the attempt of the infant or child to walk, but children with 
marked and progressive rachitis sometimes walk early. 

Increase in weight and in the chest circumference, an improve- 
ment in symptoms, such as ansemia and intestinal disturbances, and 



670 CONSTITUTIONAL DISEASES. 

the cessation of pulmonary complications are indications that the 
disease has come to a standstill. 

The diagnosis of rachitis before the development of the physical 
signs in the bones of the head, chest, and extremities is scarcely pos- 
sible. Monti thinks that an increase of lactic acid in the stomach 
contents is, if there are intestinal disturbances, strong presumptive 
evidence of early rachitis, but the increase of lactic acid may be tem- 
porary, and the general practitioner will find it hard to estimate. 
Once the bone symptoms develop, there is no difficulty. In cretinism, 
Mongolian idiocy, and syphilis, there are changes in the bones which 
very closely resemble those seen in simple rachitis. Yet in all these 
conditions there are other signs which will make the diagnosis clear. 
In syphilis, rachitis is an accompanying condition. There is no 
etiological connection between the two affections. In every case of 
tetany, spasmus nutans, laryngismus, congenital stridor of the lar- 
ynx, inspiratory apnoea, or eclampsia, the physician should not fail 
to look for evidences of rachitis. The improvement in these con- 
ditions will often depend on the management of the rachitis. 

If the infant cannot stand, the limbs may exhibit a variety of 
pseudoparalysis. Paralysis may be excluded by making an electri- 
cal muscle test. Although infants Avith rachitis will not stand, 
they move the lower extremities vigorously when lying down. 
This is not the case in the palsies ; the faradic and galvanic muscle 
tests and the presence of the normal reflexes will fix the diagnosis. 
In severe cases of cranial rachitis, it is not always an easy task to 
exclude hydrocephalus. While marked hydrocephalus presents no 
difficulties, a slight hydrocephalus is not always apparent. In such 
cases the head circumference is measured once a month. An 
abnormal increase in the circumference, a wide tense fontanelle, 
and open sutures indicate hydrocephalus. 

Occurrence. — West has demonstrated that rachitis in the United 
States is not confined to negroes and immigrants. He has shown 
that its greatest frequency is among the natives of Eastern Ohio. 

The Blood. — Through a study of the l)lood in rachitis Morse has 
come to the conclusion that anaemia of any form may exist. It is 
generally an anaemia in which the number of red blood-cells is nor- 
mal or nearly so. The haemoglobin is reduced, and there is a con- 
sequent reduction in specific gravity. There is leucocytosis, especially 
in the cases with splenic enlargement. 

Rachitis tarda is a term applied by Kassowitz and Genser to 
those cases which, instead of running their course in two or at most 
three years, continue in the active stage for eight, ten, or even 
twelve years. Kassowitz and his pupils record cases of florid rachitis 
at the tenth and twelfth year. I have seen a case of florid rachitis 
in a female child eight years of age. She had all the signs of rachitis 
of the head, thorax, and arms, The lower extremities were perma- 



RACHITIS. 671 

nently crossed in tailor fashion. The bones were painful, and those 
of the lower extremities were the seat of multiple fractures. The 
teeth were decayed. In Genser's case the milk teeth having de- 
cayed and fallen out, the permanent ones failed to appear. 

Prognosis. — If rachitis is not complicated by any intercurrent 
affection, the prognosis, even in the severe forms, is generally good 
so far as life is concerned. On the other hand, an intercurrent af- 
fection, such as pertussis or bronchopneumonia, is likely to run a 
severe course and prove fatal in a rachitic subject. If the rachitic 
process is complicated by nervous disorders, it is frequently fatal. 
Sudden death in eclampsia, tetany, or laryngismus is not uncommon. 

The prognosis as to deformity will depend on the severity of 
the affection. Subsequent treatment will not always correct deformity 
of the pelvis and long bones. The conditions often remain perma- 
nent. Fortunately rachitis in this country is not among the native 
born of so severe a type as in Germany, Austria, and Switzerland. 
If marked hydrocephalus is a complicating condition, the prognosis 
is bad. 

The treatment of rachitis differs greatly in different countries, 
but there are certain fixed principles upon which all methods are 
based. Prophylaxis is an important element in all methods. An 
infant at the breast should not be weaned too soon if the breast milk 
is sufficient in quantity and the infant is increasing in weight. 
Weaning should not be attempted until the ninth month. If it is 
done in the fall or winter, the milk should be obtained as soon as 
possible after the time of milking. There is no need of sterilizing 
the milk if it has been collected with care. It is at most pasteurized. 
Cows' milk should be diluted so that the albuminoid elements may 
be reduced. Articles of diet rich in albumins, such as eggs, should 
not be given early, nor should the infant be permitted to eat 
meat in any form, potatoes or vegetables. The early use of these 
articles of diet favors the development of rachitis. When the breast 
milk is insufficient, it should be supplemented by the requisite 
number of artificial feedings. Rachitic infants do bettor on two 
breast-feedings a day with several artificial feedings, than on arti- 
ficial feeding alone. Cows' milk is the substitute for the breast. 
It should be properly prepared. Many severe forms of rachitis 
can be traced to the use of infant foods. 

Artificially fed infants should, after the sixth month, be allowed 
a limited amount of fresh fruit juice once a day. Orange juice is 
best, but cannot be borne by all infants. An infant should not be 
allowed to become inordinately constipated. In other words, treat- 
ment is directed toward eliminating all predisposing factors to the 
development of the disease. Some breast-fed infants do not thrive. 
They develop serious disturbances of nutrition and colic, remain sta- 
tionary in weight, and have irregular and green curdy movements, 



672 CONSTITUTIONAL DISEASES. 

In such cases, the infant should be weaned or given another wet- 
nurse. Damp, ill-ventilated dwellings predispose to the develop- 
ment of rachitis. 

Bathing. — Young infants should not be bathed in water which is 
much below the temperature of the body. Such bathing prevents 
increase in weight and causes disturbances of nutrition. The tem- 
perature of the bath should be practically the same throughout 
infancy. An infant cannot be hardened without disturbing the 
metabolism. The addition of sea salt to the bath water is advised 
by some physicians, and brine baths are in general use. There 
are other kinds of baths which contain iron, but I have had no ex- 
perience with them. They are not used in America. 

Living at the sea-coast is believed to exert a very favorable in- 
fluence upon rachitic infants and children. On the other hand, if 
there are affections of the chest and lungs, such as bronchitis of a 
chronic variety, the humid atmosphere of the coast is not likely to 
be beneficial, and mountain resorts are better. 

Medicinal Treatment. — Cod-liver oil has long been a favorite drug 
in the treatment of rachitis. It should be given in the emulsion 
with the hypophosphites of lime and soda. An infant a year old 
should take half a teaspoonful three times daily. In intestinal dis- 
turbances, it should not be administered, for fear of aggravating the 
symptoms. The external application of the pure oil to the body can 
hardly be useful, since it certainly interferes with the metabolism of 
the skin. 

Iron in the form of the hypophosphate, grain j (0.06) 
given four times a day, or the saccharated carbonate, grain ij 
(0.12) three times daily, is of great utility. The pomate of iron 
or the more digestible peptonates of iron and manganese are much 
used. The combination of thyroid extract and iron has, in some 
cases of extreme anaemia with enlarged spleen, been of great utility. 
I have used this combination only in cases where there was extreme 
anaemia with rachitis : 

Thyroid ext gr. J (0.03). 

Saccli. carb. iron gr- iij (0.2). 

Tabes pulv. t. i. d. 

Henoch has advocated the use of thyroids in the advanced cases 
of rachitis. His view is opposed by other authorities (Monti). I 
advise the cautious use of thyroids in combination with iron in 
selected ambulatory cases only. Hospital cases will not do well 
on this therapy. 

The lactophosphate of lime is advised by some authorities, but 
is of little value. 

Phosphorus. — It has been shown by Kassowitz and Wegner, 
and confirmed by Virchow, that in the lower animals phosphorus 



RHEUMATOID ARTHRITIS. 673 

administered in sufficient dosage causes an increased activity in the 
processes at the epiphyseal ossification zone. The bone becomes 
more compact, but there is neither an increase of its diameter nor 
defi3rmity. Kassowitz has contended that the same results are ob- 
tained in the human subject. On this question, there is wide differ- 
ence of opinion. Jacobi was among the first in this country to ad- 
minister phosphorus as a remedy for rachitis. He especially advises 
its use in cases of craniotabes. I have found that some children do 
well on it, while in others it causes gastric and intestinal disturbances. 
I have used the emulsion of lipanin, so much recommended by Kas- 
sowitz, as a vehicle for the phosphorus. Enough of the phosphorus 
is put into the oil to make a teaspoonful of the emulsion equal to 
^Q- grain (0.00024). Thompson's solution of phosphorus may also 
be used. Preparations of phosphorus, even those made with oil, 
deteriorate. Kassowitz advises the formula to be made up with 
recently dissolved phosphorus. 

There are those who, like Henoch, Monti, and Heubner, regard 
the phosphorus treatment of rachitis with distrust. The treatment 
of rachitis with glandular extracts is still a matter of empiricism. 
The treatment of the convulsions of laryngismus will be discussed 
in the section on that condition. 

Surgical Treatment. — It is not within the scope of this book to 
dilate on the surgical or orthopedic management of rachitic deformi- 
ties. It is, however, proper to state that it is neither right nor 
necessary to place every infant with marked spinal curvature due to 
rachitis in a plaster jacket. A young infant with marked backward 
curvature of the spine will gradually lose this deformity as its 
muscles improve in tonicity, but if placed in a plaster jacket will 
probably develop a subacute bronchitis or pneumonia. The lung is 
insufficiently inflated as it is, and becomes much more so if the soft 
thoracic walls and abdomen are encased in a plaster cast. In such 
cases the sitting posture should be avoided. The infants are kept 
in the arms or sleep on an ordinary hair mattress and hair pillow. 
It is not possible to keep them in any particular posture. Massage 
of the spine is of questionable utility. 

Operations for the correction of deformities of the long bones 
should not be carried out until the rachitic process has come to a 
standstill. Surgeons sometimes advise the correction of deformities 
in young infants by encasing the limbs in plaster while the bones 
are still soft. 

II. RHEUMATOID ARTHRITIS. 

{Arthritis Deformans.) 

This affection should be sharply differentiated from all forms of 
chronic or subacute articular inflammation. Charcot and Weil have 
described this form of arthritis in children. The cases are not com- 

43 



674 



CONSTITUTIONAL DISEASES. 



mon. 



After the publication of my case, two others were described 
in the American literature, one of the descriptions being given by 
Manges. Cases of arthritis deformans or rheumatoid arthritis in 
children are referred to by Osier (4 cases) and Henoch (5 cases). 
The onset of the disease is either sudden after an exposure to 
cold and wet, or slow. In one form, after an onset of chills and 
fever, soreness and pain in several joints appear. The child is at 
first able to be about, but, as the joints become more and more 
affected, complete disability results. The pain in the joints be- 



FiG. 148. 




Arthritis deformans in a cliild seven years old. Deformity of all the joints with fixation. 
Child forced to assume this attitude awake and in sleep. 



comes so marked as to interfere with sleep. After a few months 
the patient may be unable to walk. In some cases the en- 
largements and pain begin in the lower extremities and gradually 
involve other joints. In others the onset is slow. The joints of 
the upper and lower extremities gradually become painful, and after 
repeated attacks remain swollen and limited as to motion. The ends of 
the bones are enlarged and there is effusion in some joints. With 



CHONDRODYSTROPHTA F (ETA LIS. 675 

the progressive involvement of the joints there is atrophy of the 
muscles, as in the adult form of the disease. When the disease 
is fully developed the condition is pitiable. In my case almost 
every joint in the body, including those of the cervical vertebrae, 
was involved ; the temporomaxillary articulation, the shoulder, the 
elbow, the small finger-joints, the hips, knees, ankles, and toes, 
were all affected. The patient slept in a semi-upright posture, 
and had to be carried from place to place. There was very 
limited and painful motion in all the affected joints (Fig. 148). In 
some cases there have been exophthalmic goitre and tachycardia 
(Manges) ; in others there also has been enlargement of the lymph- 
nodes, liver, and spleen. 

Brabazon found that of 100 cases of this affection, only 3 per 
cent, occurred between the ages of five and fifteen years. Two 
theories have been advanced to explain this joint-affection ; one, 
that of Charcot and Weil, is the neurotic theory, which is plausible 
because of the bilateral nature of the affection, the atrophy of the 
muscles around the joints, the changes in the skin which becomes in 
time tense and shining, and the enlargement of the ends of the 
bones which enter into the formation of the joints. The infectious 
theory is supported by the fact that there is in many cases a diurnal 
fluctuation of temperature of a degree or a fraction of a degree above 
the normal. The lymph-nodes are enlarged ; the liver and spleen are 
also enlarged in some cases. The heart is not usually involved. 

The prognosis as to life is good. 

Treatment by massage, warm baths, and patient manipulation 
of the joints under anaesthesia, may effect slight improvement. In 
my case improvement was noted after a year of constant treatment. 
Iodide of potassium is the only drug which relieves the pain. In 
some cases it exerts a favorable influence upon the course of the 
disease. 

III. CHONDRODYSTROPHIA FGETALIS. 

{So-called Foetal Rickets; Achondroplasia, Micromelia.) 

Definition. — This is a true dystrophia of cartilaginous growth 
in the long bones, resulting in deformities which consist in a shorten- 
ing of the extremities and certain changes in the bony structure of 
the head. Cases of this rare condition have been reported in this 
country by Jacobi, Smith, Herrman, and Townsend. Thomson, of 
Edinburgh, has described the affection as of intra-uterine origin. Al- 
though Horsley and Barlow classify these cases with sporadic cretin- 
ism, they have nothing in common either with cretinism or rachitis, 
and must be regarded as a distinct pathological entity. The patients 
are far from being idiotic or presenting any of the symptoms of 
myxoedema. The case published by Townsend was that of a still- 
born infant. Parrot and Jacobi have described infantile cases. 



676 CONSTITUTIONAL DISEASES. 

Forms. — From a pathological standpoint there are three forms 
of this affcM^tion : The first is that in which there is a softening of 
the primordial cartilage, or so-called chondromalacia fcetalis ; second, 
that in which there is a cessation of growth of cartilage, so-called 
chondrodystrophia hypoplastica ; and lastly, the form in which there 
is an increased but very irregular growth of the cartilaginous part 
of the long bones, so-called chondrodystrophia hyper{)lastica. In 
all of th(is(; forms the resulting deformities are characteristic. They 
are as follows : 

(a) The skull has a peculiar form, the vertex is large. The root 
of the nose in one set of cases is sunken ; in another set the whole 
nose is flattened. In both sets of cases a peculiar expression is given 
to the face, which at first was mistaken for cretinoid. The form of 
the skull was thought by Virchow to be due to a premature synos- 
tosis of the three bones comprising the tribasilar bone ; this has since 
been dis])rov(Kl, l)eing true of only one set of cases ; in some cases 
the whole tribasilar bone is cartilaginous, and in others there is no 
syncjhondrosis, nor even a marked shortening or premature syn- 
chondrosis. The changes in the skull are of the same nature as 
those in the long bones, viz., dystrophic. 

(I)) Th(! long bones in the most characteristic types are shortened. 
The diaphysis is short and thick, so as to present little or no medul- 
lary canal ; the epiphyses are mostly cartilaginous and enlarged, and 
the whole bone is bent, the normal curve being exaggerated. The 
j)icture thus presented is that of a dwarf with short extremities 
(n)i(!i-oni('lia). There are forms of chondro(lystro])hia without any 
marked shortening of the extremities, but rather of the lower part 
of the trunk (Klebs, Kaufmann) (Fig. 149). 

Morbid Anatomy. — There are no changes in any of the internal 
organs. The parts at the base of the brain, the ])ons, may extend 
above the sella tunnca in an upward instead of a forward direction. 
This is due to the peculiar changes present at the base of the skidl. 
The pituitary body is normal. The thyroid shows no marked changes. 
The flat bones are norjnal ; but in tlie bones which are formed from 
cartilage, the so-called endochondral ossification is disturbed. These 
bones, such as the sternum, patella, and costal cartilages, the tarsal 
and metacarpal bones, show changes. The long l)()nes present endo- 
chondral disturbances ; there is an absence of the long lines of car- 
tilaginous cells, and at the ossification zone there is a most irregular 
proliferation of cartilage-cells and ossifi(;ation. It is thus that the 
growth of the long bones, of the innominata, and of the bones at the 
base of the skull are disturbed. The vertebral column may be normal, 
or the anter()-])()sterior diameter of the vertebnc may be shortened. 
The thorax is small and flat, due to arrested develo{)ment of the ribs. 
On section the bones present no parallel rows or cartilage-cells, no 
medullary spaces, no projection of medullary bloodvessels into the 



CHONDRODYSTROPHIA FCETALIS. 
Fig. 149. 



677 




Chondrodj'strophy (achondroplasia). Seventeen years of age. 



Anterior view, showing depressed root of 



Posterior view, showing large head, low 



nose, short extremities, peculiar articula- shoulders, normal size of trunk, short scap- 
tion at the knee, and well-developed gen- ulae, lordosis in the lower lumbar region. 



Itals. 



and muscular legs. 
(Case of Dr. Chas. Herrman.) 



cartilage. There is an absence of vessels at the ossifying junction, 
the bone being formed mainly from the periosteum. The heads of 



678 CONSTITUTIONAL DISEASES. 

the bones are thus chiefly made up of hyaline cartilage ; the shaft of 
the bone of periosteal bone-formation. 

From the above data of the morbid anatomy in this disease it 
can be seen why this condition has nothing in common with rachitis 
and cretinism, and should not be called foetal rickets or " so-called ^^ 
foetal rachitis. 

Symptoms. — The general picture is that of a dwarf with short 
extremities and a body trunk of normal length. The four extremi- 
ties are affected. The arms are shorter than the forearms, the thighs 
than the legs. The head is large, at times simulating a hydroceph- 
alic contour, the parietal and frontal bones are prominent, the root 
of the nose is broad, the bridge depressed, the tip large and the nos- 
trils open, the features are large and heavy. The vault of the palate 
is high. The lumbar curve of the spine forward is much exagger- 
ated, the sacrum thrown back, causing in the female a narrowing of 
the brim. The hips are large and muscular, as also the muscles of 
the extremities and trunk. The lower extremities are bowed and 
the legs are articulated at an angle with the thigh. The hands are 
square, massive, reduced in all proportions, the fingers of equal 
length, thus giving, when spread, the appearance of a trident. The 
intelligence is very good ; in some cases the subjects may not be as 
bright as the normal individual. 

Diagnosis. — A differential diagnosis must be made from Rachitis, 
Cretinism, Infantilism, and Osteogenesis imperfecta. A careful 
study of the symptomatology will show quite distinctly that the 
characteristics of each of these conditions cannot be mistaken for 
each other. 

Prognosis and History. — Many of these cases die at birth, 
but many attain adult life and are of good intelligence, though some 
cases may have less than the normal intelligence. They may have 
children. The children of the female sex may have chondrodys- 
trophia ; though among the handsomest that I have ever seen were 
the offspring of a female chondrodystrophic dwarf, whose children 
were patients in my clinic. This dwarf had little difficulty in labor, 
though in some cases this difficulty may be present. Her children 
presented absolutely no deformities, but were brought for treatment 
for the slight disturbances of infancy and childhood. 

OSTEOGENESIS IMPERFECTA. 

{Fragilitas Ossium Idiopathica.) 

This is a systemic disease of the bones which attacks the young 
foetus and, without causing appreciable abnormalities in other organs, 
prevents or disturbs the normal development and calcification of 
osteoid tissue. The disease manifests itself by defective develop- 
ment of the cranial bones, with fragility of the entire osseous skele- 



PLATE XXT. 




Ostecgenesis Imperfecta, showing Fractures of 
the Long Bones ^A^ith Resulting Deformities. (Case 
of Dr. Nathan.) 



OSTEOGENESIS IMPERFECTA. 679 

ton. Cases of this nature have been reported in the foetus or in the 
newborn infant — born dead or dying within a short time after 
birth ; recently however, cases have appeared in the literature which 
have lived to adolescence with all the symptoms of the affection. 

Morbid Anatomy. — The examination of the bones after their 
removal from the body shows them to be delicate and fragile, frac- 
turing with the slightest force. At times the periosteal bone shell is 
so thin that it may be crushed between the fingers with very little 
force. Sections of the bones show them to be porous, the trabeculse 
delicate, the outer layer exceedingly thin, there being no dense bone, 
but a collection 'of small plates and trabeculse. Calcification of the 
osteoid tissue is defective or entirely absent in places. The epiphy- 
seal cartilages are normal, both in size and consistence. Microscop- 
ically, it is revealed that the process is confined entirely to the shaft 
of the bone, where the normal development and calcification of 
osteoid tissue is lacking. The formation of rows and their subse- 
quent calcification and disintegration go on in a normal manner. It 
is at the stage of true bone-formation that the disease is manifest. 
The osteoblasts are diminished in numbers and deposit only a thin 
layer of osseous tissue. Calcification is thus delayed, deficient, or 
entirely absent. The other organs of the body are entirely normal. 

Symptoms. — The general appearance of the newborn infant with 
osteogenesis imperfecta is characteristic. The skin and the sub- 
cutaneous tissue may be thickened ; on the other hand, they may 
be quite normal. The extremities are not shortened as the result 
of the cessation or retardation of growth, but are bent and de- 
formed and may be the seat of multiple fractures. The ribs may 
be the seat of fracture. Some of these fractures may have united in 
utero, in which event we have the resulting deformity. Fractures 
may be so numerous as to give the long bones a nodular appearance. 
All the bones of the body partake of this fragility. The spinal 
column is soft and fragile, presenting anteroposterior and lateral 
deviations. The ribs may be fractured to an excessive degree. In 
Merkel's case no less than forty-three fractures were present. The 
clavicle shows fractures very similar to what is seen in cases of 
rachitis. The cranial bones show defective ossification, as is evi- 
denced by the widely open sutures, or the cranial vault may consist 
simply of a membranous sac. 

Dr. Nathan has published cases of osteogenesis imperfecta 
observed from infancy to advanced childhood or adolescence. He 
lays stress particularly upon the fact that the fractures in these 
children at first are scarcely observed. The slightest traumatism, 
such as a jar against some object, may produce these fractures. In 
some of his cases fractures occurred in the long bones, at various in- 
tervals, no less than thirty-five times. They occur soon after birth 
and may be present, though unsuspected, when the child is born. 



680 CONSTITUTIONAL DISEASES. 

When born, children are, as a rule, very weak and are carefully 
handled, for which reason fractures are not so likely to be observed 
at this time; as soon, however, as the general health improves and 
the children are allowed more liberty of motion fractures occur. 
They are attended with less pain and inflammation than in the 
normal individual, due, no doubt, to the slight traumatism. Union 
takes place rapidly and is usually firm. In some cases complete 
fracture does not occur, but infraction, resembling in a general 
way what is seen in rachitis. Some individuals not only survive 
childhood and learn to walk but may attain adolescence suffering 
from this disease. 

Differential diagnosis must be made from chondrodystrophia 
foetalis. In the latter disease the prognathous expression of the 
face is characteristic, with flattening of the nasal region ; the bones, 
though shortened, are dense and hard, and, aside from slight bowing 
of the legs, are not deformed. In later life the chondrodystrophic 
individual is a dwarf, with shortened extremities and no predisposi- 
tion of the bones to fracture. 

Osteogenesis imperfecta is differentiated from rachitis by the ab- 
sence of the rib rosary, the enlarged epiphyses, and other states char- 
acteristic of the disease. We can scarcely confound this disease with 
hereditary syphilis, or sarcoma or any new growth of the bone, or 
osteomyelitis. The dystrophy of syphilis is so characteristic as to 
bear no resemblance to the disease just described, the chief charac- 
teristics of which are fragility of the bones associated with defective 
ossification of the cranial bones. 

The etiology of this disease is as yet a matter of speculation. 

Its treatment must be founded on general indications, increasing 
the strength of the patient and protecting the bones from fracture. 

IV. DIABETES MELLITUS. 

Diabetes mellitus is of very rare occurrence in infancy and child- 
hood. Simon says that he has met it in nurslings, but Monti doubts 
whether it can occur under the age of one year. In all his experience 
he has never seen such a case. Leroux, quoted by Monti, collected 
147 cases of diabetes in children. The majority occurred between 
the fifth and tenth years. Of 159 cases collected by Saundby, 129 
occurred between these years. Cotton has, in a recent article, shown 
that in children the ratio of deaths from diabetes to the whole death- 
rate is 0.04 per cent, in Chicago, and 1.2 per cent, in New York City. 

The etiology of diabetes in children is practically the same as in 
the adult subject. Frerichs, Blanchard, Parry, and Roberts have 
shown that heredity plays an important role. In a case coming 
under my observation a sister of the patient had died of diabetes 
and four members of the family on the mother's side. In an 



DIABETES MELLITUS. 681 

instance reported by Roberts, 8 children of the family had died of 
it. It appears that in certain families there is a tendency to con- 
tract diabetes. There is no ground for assuming that diabetes in 
children follows traumatism or the infectious diseases, such as scarlet 
fever, measles, diphtheria, etc., any more frequently than in the 
adult. In some statistics, the sexes are shown to be equally affected. 
In others the disease is given as more prevalent in one or the other. 
Lemonnis has seen diabetes complicate congenital syphilis, tuber- 
culosis of the lungs and of the mesenteric lymph-nodes. I have had 
a case complicated with tuberculosis of the mesenteric lymph-nodes. 

The symptoms of diabetes in children, as given in the cases thus 
far published, do not extend over so great a period as in the adult. 
The cause of this must lie in the fact that there is a long period 
during which the symptoms are slight or escape notice. In a case 
which recently came under my care the child, nine years of age, 
showed symptoms only five months before she came under observa- 
tion. At that time the mother noticed that the appetite was vora- 
cious and that there were great thirst and frequent urination. In 
spite of the large quantity of food and liquid taken, the child lost in 
weight. The amount of urine passed may be quite large. In Cot- 
ton's case it reached 104 ounces, in mine, 70 ounces daily. Monti 
has seen as much as 1 6 litres passed in twenty-four hours. Heubner 
and Hirschsprung found that the daily excretion of sugar may be 
from 30 to 113 grammes to the litre. 

In most of the cases recorded there has been polydipsia. The 
skin is the seat of a lichen-like eruption which causes intolerable 
itching. Furuncles and boils are also of common occurrence. The 
urine may contain albumin, and hyaline and granular casts. In 
my case albumin was present, but no casts. There is as a rule 
constipation. The temperature may be normal or subnormal. If 
there is complicating tuberculosis, there will be a slight daily rise 
of temperature toward evening. In all the cases thus far published 
there was progressive emaciation. Acetone in the odor of the 
breath and diabetic coma preceded by intervals of delirium close 
the clinical course of the disease. 

The methods of diagnosis do not vary from those pursued in the 
adult. The urine of a child suffering from polyuria, polydipsia, a 
voracious appetite, pruritus, and progressive emaciation, should be 
carefully examined for sugar. Infants who take foods such as 
malted milk, containing an enormous quantity of sugar, often show a 
temporary glycosuria, which should not be mistaken for true dia- 
betes, and which is not attended by any of the clinical symptoms 
of that disease (Epstein, Koplik). 



682 CONSTITUTIONAL DISEASES. 

V. DIABETES INSIPIDUS. 

{Polyuria.) 

This is rare in infancy and childhood. If the daily amount of 
urine is three or more times the normal amount, there is polyuria. 
The specific gravity of the urine does not exceed 1006. Ebstein 
collected 10 cases in which the symptoms developed as a result of 
a cerebral inflammation in the vicinity of the fourth ventricle. The 
affection is sometimes hereditary. Cases have followed fright, the 
infectious diseases, meningitis, and traumatism. The cause is fre- 
quently obscure. The onset may be gradual or acute. Sometimes 
intense thirst or nervous symptoms usher in the disease. The nutri- 
tion may be maintained for years. The skin is dry, the body 
temperature below normal, and the symptoms do not differ from 
those manifested in the adult. The following case from my clinic 
was published by my assistant, Dr. Lewi : 

Walter A., set. seven years, was first seen at the dispensary. The 
family history was, for the most part, negative, except that three 
children had died of nervous diseases, one of them, aged three years, 
of spinal meningitis, and two others, when babies, of convulsions. 
The patient when a baby was healthy ; he was breast-fed one year 
and had never had a convulsion. When two years old he had vari- 
cella, followed by pertussis ; at the age of five he had measles, com- 
plicated with an obstinate conjunctivitis, but recovered. In Octo- 
ber, 1892, while driving, he was thrown from a carriage in rapid 
motion, striking the right side of the head ; no ill effects were noticed 
at the time. In January, 1893, he began to complain of pain in 
the back and in the nape of the neck. At about the same time 
it was noticed that he arose several times at night to urinate, and 
would invariably drink water after micturition ; the mother noticed 
that he grew very nervous ; the frequent micturition and increased 
thirst gradually became noticeable during the day, becoming so per- 
sistent that he was obliged to leave school. He was placed in a hos- 
pital, where he remained seven months ; Avhile there he lost flesh ; 
none of the symptoms improved. He was on a rigorous milk diet 
during the entire time. 

Status Prwsens. — January 19, 1894, the child complains of pain 
on the right side of his head ; says he feels chilly all the time and 
cannot stand still a moment. His face is pale and has an old person's 
look, with features sharp and pinched. The eyes are large and 
prominent, and the veins of the forehead dilated. The skin is exceed- 
ingly dry. The head is well shaped ; careful palpation shows no 
sensitive spots. The chest is emaciated, with a slight rachitic girdle. 
The lungs, on auscultation give increase of voice-sounds at the right 
apex. The heart is normal, also the abdomen. The epiphyses of 
the ankles are enlarged. The glands at the angles of the jaw are 



DIABETES INSIPIDUS. 683 

enlarged, also those in the left axilla. Urinary symptoms : the child 
is passing a very large amount of urine ; wakens on an average ten 
times a night to do so. The thirst varies with the amount of water 
passed ; for the last few weeks he has complained of painful mictu- 
rition. His appetite is excellent ; he is on a milk diet. Weight is 
thirty-seven pounds ; temperature (per mouth) 97.8° F. (36.5° C). 
The urine examination was as follows : quantity in twenty-four 
hours, 6400 c.c, colorless ; specific gravity 1.003 ; reaction acid, no 
albumin, no sugar. Microscopical examination negative. 

A series of quantitative urea tests were made in this case. The 
general consensus of opinion is that in cases of diabetes insipidus 
the amount of solids, including the urea, is increased. The tests 
were made with the Doremus ureometer. A control test was always 
made. The table shows marked diminution in the amount of urea. 
In order to avoid error, fresh bromine was used. 

Date. Sp. grav. Amoimt in 24 hours. Urea. 

1.003 6.300 e.c. 6.3 grammes. 

1.003^ 

1.005 

1.002 

1.004 

1.002^ 

1.003 

1.003 

1.003 

Apr. 2. 1.0031 

The treatment has been successful in some respects. The child 
was at once put on a general diet. Antipyrin was given. After the 
first few days there seemed to be an abatement of the nervous symp- 
toms and slight diminution in polydipsia, but no permanent im- 
provement. He was then given opium several weeks without result. 
Ergot was next given, and continued for about two months ; under 
this treatment the pain on the right side disappeared ; the restlessness 
became less, and the thirst likewise diminished. Under a generous 
diet the child has held his own ; he still weighs thirty-seven pounds, 
his color is healthy, and the mucous membranes are normal. 

Keferences of Authorities for Collateral Reading. 

Bdumler, Ch.: "Gelenk Rheumatismus," Deutsche. Klinik, Bd, ii,, 1901. 

Benecke: Die gonorrhoische Gelenkentziindung, Berlin, 1899. 

Cotton: ''Diabetes in Childhood," Jour, Amer. Med. Assoc, 1901. 

Charcot's works. Arthritis Deformans, New Sydenham edit., vol. iii. 

Hansemann, D. von: Rhachitis des Schiidels, Berlin, 1901. 

Heubner, O. : "Rhachitis u. Versuch mit Schildriisen Saft zu behandl.," 
Charite Annalen, xxi. 

Jacobi, A.: "Acute Rheumatism in Infancy and Childhood," Amer. Clin. 
Lectures, 1879. 

Kopilk, H. : ** Arthritis Deformans in a Child," Arch, of Red., 1896. 

Kassowitz, M. : Rhachitis, i. and ii. Abtheil, Wien, 1882-5. 

Normale Ossification, Wien, 1881. 

Symptome der Rhachitis, Leipz., 1886. 



Jan. 


25. 


Feb. 


4. 


« 


6. 


a 


8. 


u 


10. 


11 


17. 


i( 


24. 


Mar 


18. 


" 


30. 



unt in 24 hours. 




6.300 e.c. 


6.3 


6.300 " 


6.8 


5.200 " 


7.2 


7.000 " 


6.5 


5.500 " 


6.8 


7.500 " 


7.8 


6.400 " 


6.5 


7.000 " 


8. 


7.300 " 


7. 


6.400 " 


6.8 



684 CONSTITUTIONAL DISEASES. 

Lewi, E.: " Diabetes Insipidus," Arch, of Ped., 1894. 

Miller, J, D. Milton : " Acute Articular Rheumatism in Infants," Trans. Amer. 
Ped. Soc, vol. xi. 

Moncorvo : ''Rheumatism Blennorrhagique Ches. les Enfants," La Med. Infant, 
1894. 

Morse, J. L. : " Rickets," Phila. Med. Jour., 1900. 

''Study of the Blood in Rickets," Medical and Surgical Report, Boston 

City Hospital, 1897. 

West, J. P. : "Rickets in Eastern Ohio," University Med. Mag., 1895. 

Weil: " Arthritis Deformans," Nouvelle Iconographique, 1890. 

2kueifel, P. : Aetiol. Prophylax. u. Therapie der Rhachitis, Leipzig, 1900. 



PLATE XXIL 




Topography of Enlarged Lymph-nodes. 

1. Preauricular enlarged, with disease of the external auditory canal, or any eruption on the 

face, or parotitis. 

2. Tonsillar nodes. 

3. Submaxillary enlarged, with disease of the mouth, or skin eruptions over the lower jaw. 

4. Submental enlarged, with chin eruptions. 

5. Retropharyngeal enlarged, with infections of the pharynx and the retropharynx. 

6. Nodes behind the border of the trapezius muscle enlarged, with disease of the scalp. 

7. Nodes behind posterior border of the sternomastoid muscle enlarged, with infections of 

the retropharynx or the scalp. 

8. Postauricular nodes enlarged, with mastoid disease or scalp infections. 

9. Nodes above and behind the clavicle enlarged, with infections of the neck or mediastinum. 

10. Nodes enlarged in infections of the hand or in eruptions such as those of syphilis. 

11. Axillary enlarged, with infections of the arm, the axilla, and the upper chest. 

12. Nodes of the inguinal region enlarged in infections of the lower extremity, syphilitic or 

other lesions of the genitals. 



SECTION IX. 

DISEASES OF THE LYMPH-NODES, DUCTLESS GLANDS, AND 

THE BLOOD. 

I. DISEASES OF THE LYMPH -NODES. 

In any disease or irritation of the scalp the nodes of the 
neck may be enlarged behind the border of the stern om as toid. 
The onset of some diseases of infancy, such as rotheln or rubella, 
is indicated by slow enlargement of these glands. Infection of the 
tonsils will cause the lymph-nodes at the angle of the jaw to en- 
large and sometimes to suppurate. In young infants and chil- 
dren, chronic enlargement of the tonsils with adenoids causes an en- 
largement of these nodes. Tuberculous glands may occur in this 
region. The post-auricular lymph-nodes enlarge in disease of the 
ear or of the adjacent parts of the scalp. Parotitis will cause a 
sympathetic swelling of the lymph-nodes in front of the parotid, 
and also below this gland at the angle of the jaw and beneath it. 

Retropharyngeal adenitis will cause the nodes behind the pharynx 
to swell and to appear at either side of the neck in front of the 
border of the sternomastoid muscle. 

Any eruption on the chin will cause an enlargement of the 
lymph-nodes from the tip of the chin to the hyoid bone. 

Swelling at the angle of the jaw will frequently simulate par- 
otitis. 

In certain forms of congenital syphilis with mucous patches on 
the lips and at the angles of the mouth (rhagades) there is beneath 
the body of the jaw a symmetrical enlargement of the lymph-nodes 
of both sides (syphilitic adenopathies). The lymph-nodes of the 
groin will enlarge in balanitis of the prepuce, syphilis, tubercu- 
losis of ritual circumcision, and also in eczema and intertrigo of the 
inguinal folds. The lymph-nodes of the femoral region will in 
infants and children enlarge or suppurate as a result of any infection 
of the foot, leg, or thigh. 

In the later stages of tuberculosis, either of the lung or peri- 
toneum, there may be a general enlargement of the nodes of the 
neck, axilla, groin, and elsewhere. In many infants and children 
of a lymphatic diathesis (lymphatism), the nodes of the neck and 
groin show slight enlargement. Such enlargements should not, in 

685 



686 DISEASES OF THE LYMPH-NODES. 

the absence of positive signs of tuberculosis elsewhere, be hastily 
pronounced tuberculous. After the exanthemata, the lymph -nodes 
of the neck, groin, and other regions may remain slightly enlarged. 
These enlargements usually retrograde to the normal in time, but if 
they remain rarely give rise to symptoms. 

The physician should exclude every possible infection before con- 
cluding that an enlargement of the lymph-nodes in infancy and 
childhood is of a tuberculous nature. Cases of rachitis will show 
very slight enlargement of the lymph-nodes, especially in the ingui- 
nal regions. Forms of anaemia, such as von Jaksch's disease, also 
show these enlarged nodes. The lymph-nodes may be the seat of 
primary malignant disease, as in forms of lymphosarcomata. In 
malignant growths of the internal organs, such as the kidney, etc., 
they may be the seat of metastatic deposit. They are enlarged in 
acute and chronic forms of leukaemia and Hodgkin's disease. In 
these diseases the spleen and liver are also enlarged. 

Acute Adenitis. 

( A cute Lymphadenitis. ) 

The lymph-nodes in infants and children are peculiarly susceptible 
to acute infections, which are for the most part pyogenic (staphylo- 
coccic and streptococcic). Van Arsdale collected 500 cases of acute 
lymphadenitis seen in his experience. He found that 77 per cent, of 
them were in children. They are especially liable to the cervical 
infections. Eighty-five per cent, of the cases in children were infec- 
tions of the lymph-nodes of the neck, the frequency in adults being 
only half as great. 

Etiology. — Most of the infections of the lymph-nodes in chil- 
dren are, according to Van Arsdale, acute (79 per cent.). The ma- 
jority of them are pyogenic. Children are subject to acute infections 
of the scalp, face, mouth, nose, tonsils, and mucous membrane of 
the nasopharynx. The lymph-nodes draining these regions are in 
the direct line of infection. Thus eczema and skin eruptions of all 
kinds, stomatitis of all varieties and inflammation of the tonsils and 
the nasopharyngeal space, will give rise to enlargement of the lymph- 
nodes. If the infection is severe, suppuration occurs. It is owing 
to these causes and to the breaches of surface caused by slight trau- 
matism that this form of adenitis is so common. The essential excit- 
ing cause of acute lymphadenitis is the invasion of the nodes by 
pyogenic bacteria entering through the lymph-channels. 

The symptoms of lymphadenitis in infants and children are 
essentially the same as in the adult subject. The node is at first felt 
as a hard nodular mass beneath the skin. One node or several may 
be infected. There is always some fever. At first the skin over 



CHRONIC LYMPHADENITIS. 687 

the node is of normal color, but, as the inflammation progresses, it 
becomes involved, red, and finally, if not treated, there will develop 
all the signs of an ordinary abscess. 

The diagnosis is not difficult. The history and general course 
at once point to the nature X)f the disease. When the region about 
the parotid is affected, it is at times difficult to tell whether there is an 
infectious parotitis, or whether the nodes just beneath or above the 
parotid are involved. A preauricular gland situated in front of the 
ear on the parotid gland is apt to enlarge and suppurate. The nodes 
underneath the angle of the jaw and in front of the border of the 
mastoid sometimes enlarge and suppurate, involving the parotid by 
collateral swelling. In all of these cases, it is important to remember 
that a line drawn parallel to the lower border of the body of the jaw 
marks off the parotid above, and the lymph-nodes below. In excep- 
tional cases, the swelling of infectious parotitis may extend lower 
than this line. 

The treatment of acute lymphadenitis is at first abortive. Cold 
applications to the nodes which are enlarged and accessible, such as 
those of the neck, relieve the pain and in many cases lessen the 
severity of the reaction. This result is frequently seen in cases where 
infection of the nodes of the neck results from tonsillitis. Some- 
times, in spite of all that can be done, suppuration occurs as a result 
of infection of cervical, axillary (vaccination), and inguinal nodes. 
In that case, the affected node should be incised. The further treat- 
ment of such cases is surgical. 



Chronic Lymphadenitis. 

Chronic or subacute enlargement of the lymph-nodes in children 
may be pyogenic, tuberculous, or syphilitic. Of the cases collected 
by Van Arsdale, only 21 per cent, in infants and children were of 
chronic pyogenic origin, as against 12 per cent, in the adult. On the 
other hand, only 6 per cent, of all the cases of adenitis in infants 
and children were tuberculous. In the adult, the tuberculous forms 
of lymphadenitis are twice as frequent as in children. It is thus 
seen that even in chronic enlargements of the lymph-nodes of 
infants and children the occurrence of tuberculous forms gives the 
lowest percentage. 

The symptoms of chronic enlargement of the lymph-nodes in 
infants and children are nodular tumors corresponding to the 
affected lymph-nodes. The enlargement may be single or multiple. 
Sometimes a whole packet of nodes is enlarged. The nodes 
most commonly enlarged are those at the angle of the jaw. This 
occurs in infants and children who suffer from chronically en- 
larged tonsils and adenoids. As a rule the nodes affected 



688 



DISEASES OF THE THYROID GLAND. 



remain enlarged for months. At times they are somewhat less 
swollen. They do not suppurate unless there is a tendency to a 
breaking-down of tissue. In all of these cases there is not only 
toxic irritation, but also a true hyperplasia of the tissue of the 
glands. I have seen these nodes removed and opened. Some 
of them have a soft, broken-down centre resembling that of the 
tuberculous nodes. 

The treatment of chronic lymphadenitis is directed toward 
removing the source of infection. If the tonsils are enlarged and 
adenoids are present, they should be removed. A tonic course of 
treatment, good food, out-of-door exercise, iron, and cod-liver oil 
is indicated. In spite of these measures many cases do not improve. 
If the enlargement of the nodes in such cases is localized, the question 
of the advisability of removing them arises. That measure should 
not be resorted to unless there is a reasonable certainty that they are 
tuberculous, and when all other treatment has failed. 

II. DISEASES OF THE THYROID GLAND. 

General enlargement of the thyroid is not uncommon in in- 
fancy and childhood. Normally the thyroid gland, and especially 
its isthmus, can be made out only by careful palpation. The isthmus 







Fig. 150 






# 


f^^^^^^^^^ 




^ 


-K 


J^H 


Ik 


a' 




jH 


Ik 


\. 


.0^ 


^ 


V 


A' 




^ 


^^^K'' 


/ 




X 


^^Kk 


. ^ 


r 


^^-x \ 


^R 



Enlarged thyroid in a child. 



is indicated by a very slightly raised structure passing across the 
trachea beneath the cricoid cartilage. The lateral lobes cannot be 



PLATE XXIII. 




sporadic Cretinism. Child fifteen months of age. 



SPORADIC CRETINISM. 689 

palpated. In cretinism and dwarfism, the enlarged lateral or super- 
numerary lobes beneath and just in front of the anterior border of 
the sternomastoid muscle can be palpated. Cystic growths of the 
thyroid are seen in front of the trachea, generally just above the notch 
of the sternum. They may occur in very young infants or in chil- 
dren of four or five years of age. Enlargement of the isthmus occurs 
chiefly in girls (Fig. 150). In these cases there is a disturbance 
of the heart functions and symptoms of the onset of morbus 
Basedowii. 

Cretinism, Endemic and Sporadic. 

Cretinism is a chronic affection which is characterized by a de- 
fective growth of the bones of the skeleton in their long axes, accom- 
panied by a distinct set of mental symptoms and by changes in the 
soft parts. 

Forms. — There are two forms, the endemic and the sporadic. 

Endemic cretinism occurs in certain districts of Continental 
Europe. It does not exist in this country (Osier). The pictures 
presented by endemic and sporadic cretinism are similar. Accord- 
ing to the recent studies of Dolega, His, and Bernard, their pathologic 
anatomy is also similar. Endemic cretinism is an advanced stage 
of a degeneration beginning with goitre manifestations. The result- 
ing changes are due to " athyreosis,'^ a suspension or disturbance of 
the functions of the thyroid gland. Sporadic cretinism, although 
also due to athyreosis, occurs without goitre. The peculiar formation 
of the skull in cretinism, endemic or sporadic, is now known not 
to be due to a premature synostosis of the os basilare and the 
sphenoid, as was at first thought by Virchow. The brachy cephalic 
skull as manifested in a broadening of the bridge of the nose, and 
the prognathous expression is due to a deficient growth of the bones 
at the base of the skull, in their long axes. The sutures and fon- 
tanelles remain open for a long time. Dentition is delayed. The 
skin is myxoedematous in sporadic cretinism only. Dwarfism and 
anaemia are common to both forms. 

Sporadic Cretinism. 

Occurrence. — The disease may appear in utero or at any time 
after birth. Fully one-half of the cases develop before the eighteenth 
month (Fletcher Beach). 

Symptoms. — I have published cases in which the" symptoms 
appeared within a month or five weeks after birth. The history was 
as follows : In one case there was another cretin in the family ; in 
the others there was no such history. The birth as a rule was nor- 
mal (Fig. 151). The infant was jaundiced, but fairly well nourished. 



690 



DISEASES OF THE THYROID GLAND. 



It lay in a torpid state and was only roused when severely teased. 
The infant was easily chilled. The cry was deep and coarse. The 
forehead was low and narrow. The eyelids were puify. The 
tongue was large, broad, and thick, at times protruding from the 
mouth. The abdomen was large, and the thighs and legs were out 
of proportion to the length of the trunk. The skin had a greenish 
hue. The thyroid gland could not be found. The surface was cool 
and the rectal temperature 97° or 97.8° F. (36.1°-36.5° C). The 
blood in these early cases has foetal characteristics. There is no 







Fig. 151. 




w^' 'I^^Hi 




"^H^. 1^1^ 


m 


"1^. I^H 


1 




^^"^* fif 






^<^^i, • V\^ ^^ 


.J 


^^WplK aH^^^ 


..... ^^ 


''^filiil'i'^^**mSHB'l .' St .y' ,^^^^^^tl^^^^ 




"^^^^m^'- <4Hi^ 


■•^:sr-!-^-,. 


t^.I/f^^/lf 



Congenital sporadic cretinism. Infant, four weeks old. 



leucocytosis. In the cases which develop some months after birth 
the infant may at first be bright and normal. Six to nine months 
after birth, it may have had some slight illness, such as an adenitis, 
and after this the change was noticed, or the change may have 
occurred without any preceding illness. The infant ceases to notice 
objects about it, and becomes stupid and weaker. It may previously 
have attempted to walk or stand, but ceases to make an effort to do 
so (Plate XXIIL). The child's expression is idiotic. It has a 
meaningless smile most of the time and does not play. The skin 
has a wrinkled and myxoedematous appearance, the color t)eing not 



SPORADIC CRETINISM. 



691 



only pale, but also greenish. The nose is flattened, the lips are 
thickened, and the hair becomes dry and sparse. The forehead is 



Fig. 152. 




Sporadic cretinism ; myxoedema marked. Child, twenty months of age. 



narrow and the face has a prognathous expression — " monkey- 
like/' as one mother expressed it. There are no teeth. The neck 
is short and thick. The genitals are large for the age. The skin 



692 



DISEASES OF THE THYROID GLAND. 



of the scrotum is thickened. The ansemia in these cases is extreme. 
The haemoglobin may be as low as 18 per cent. (Fleischl). The 
leucocytes may be as high as 18,000, and the red blood-cells 
5,600,000. 

In other cases, the symptoms are at first more nearly of the myx- 
oedematous type. The skin, especially that of the face, has a greenish- 
yellow, waxy, puify appearance. The upper and lower eyelids are 
swollen, as in nephritis. With these appearances, there are the dry 
hair, the macroglossia, the guttural voice, the dwarfish appearance, 
the protuberant abdomen, and the mental dulness. The expression 
of the face is less prognathous than in the first form. In one of 
my cases, the infant was in good health until the sixteenth month. 

Fig. 153. 





^^^^ 


■s 


^^H 




Wf^^^ «f'A' 




|||H 




^l 




■^'Si^: V^^^H 




'■■ JS^A 




^^1 






1 


m 






1 


9 



Cast of the hand of a boy cretin, four years of age. Flat and spade-like in form ; it shows 
also the thickened and hypertrophied hypothenar eminence. 



It- then developed abscesses over the body, after which cretinism set 
in (Fig. 152). The abscesses were peculiar, the granulations slug- 
gish, and the pus was creamy. The skin was not oedematous but 
myxoedematous. 

In both forms the hands are large, flat, and spade-like. The 
hypothenar eminence is thick, square, and hypertrophied, as in the 
lower animals (Koplik and Lichtenstein) (Fig. 153). In some cases 
the thyroid gland cannot be felt, in others it is small, and in excep- 
tional cases there is goitre (7 cases of Osier's series). In some cases, 
supraclavicular masses of fat or fatty tumors behind the sterno- 
mastoid muscles are apparent. I have seen these masses of fat in 



SPORADIC CRETINISM. 



693 



the cases coming under my notice which had suffered a relapse after 
suspension of treatment. 

The etiology of sporadic cretinism is as yet absolutely unknown. 
Experimental and operative pathology have demonstrated that inter- 
ference with the function of the thyroid gknd (athyreosis) will 
produce a condition (myxoedema) closely resembling cretinism 

Fig. 154. 




Cretin, eighteen years of age (untreated). 



(Horsely, Reverdin, Kocher). The essential cause of endemic 

cretinism is thought to be some form of infection (Fagge). Sporadic 

cretinism is also ranked by some authors among the infections. 

Morbid Anatomy. — There are cases of sporadic cretinism in 



694 DISEASES OF THE THYROID GLAND. 

which the thyroid gland is absent. It has not developed in foetal life 
and is not found at autopsy. In other cases there is found at autopsy 
a small atrophied gland which is sclerosed and much reduced in size. 
Such cases have been published as following the infectious diseases. 
Lastly, there are cases with goitre. The changes in the thyroid, 
when it is found in sporadic cretinism, have been described by 
Barker. There is an increase of connective tissue. The paren- 
chyma is replaced by small and large irregularly shaped cells, which 
are granular and unlike the normal tissue. Some of the acini are 
almost solid ; others are cystic and filled with colloid material. The 
cells may contain vacuoles ; their nuclei may show " karyorrhexis.'^ 
The nuclear changes are characteristic of degenerative processes. 
Some of the acini are replaced by connective tissue. 

The Bones. — In the recent work of His, Dolega, and Bernard, it 
has been clearly shown that ossification in the pre-existent cartilagi- 
nous structures of the skeleton is delayed in all its phases. This is 
evinced in the delayed appearance of ossification centres, the delayed 
bony transformation of the epiphyses, and in the persistence of the 
epiphyseal zones. In some cretins, ossification is completed at a very 
late period of life ; in others, infantile conditions are perpetuated. 
The dwarfing of the whole skeleton is thus explained, not by a pre- 
mature synostosis, but by faulty proliferation and ossification of the 
epiphyseal cartilages. The bones of the skull are affected in the 
same manner as the vertebrae and the long bones, in that they fail to 
grow in their long diameters and in that ossification centres appear 
late. 

The diagnosis is not difficult in advanced cases. The early cases 
require close study. In these, the stupidity increasing to absolute 
idiocy, the retarded growth, the change in the expression, the swol- 
len eyelids, thick lips, dry hair, wrinkled myxcedematous skin, the 
flat, spade-like hands, the dwarfish appearance, and the reduced 
internal temperature, all point to the diagnosis. In later cases, the 
extreme anaemia, myxoedema, and pronounced prognathous expres- 
sion of the face are apparent. 

Sporadic cretinism must be differentiated from the following con- 
ditions : 

Mongolian Idiocy. — This is a form of genetous idiocy with which 
cretinism is frequently confounded. The idiots resemble cretins. 
The growth is stunted. The mouth is kept open. The tongue is 
large and fissured ; the papillae of the tongue are enlarged and 
erect. The tongue protrudes from the mouth (Plate XXIY.) ; the 
lips are thick ; the voice is coarse and guttural. The temperature may 
be subnormal, but is generally normal. The skin is dry and the hair 
coarse. In young infants the skin may be delicate. The patients are 
easily chilled. The musculature is flabby. The infants cannot hold 
the head erect. The occiput is flattened, the neck short and thick. 



PLATE XXIV. 




Mongolian Type of Idiocy. Child two years of age. 



SPORADIC CRETINISM, 695 

There is strabismus, and the axes of the eyelids have a Mongolian 
slant — that is to say, they converge. The inner eyelid comes down 
toward the nose with a rapid slope. The bridge of the nose is flat. 
The head is small and obtusely rounded ; the antero-posterior diam- 
eter is nearly equal to the lateral one. The fontanelles remain open 
late. The skin, however, is not myxoedematous, nor is the expression 
prognathous as in the cretin. The anaemia is as a rule marked ; 
in some cases the skin has a greenish hue. There is a curving inward 
of the tip of the little finger. The second phalanx is short and the 
terminal phalanx displaced. West has shown that although this 
deformity is very common in these idiots, it is not pathognomonic of 
Mongolian idiocy. Many of the subjects grow to adult life and have 
some degree of intelligence. 

The Dwarf with Idiocy. — There may be several of these dwarfs in 
a family. The thyroid gland is enlarged at the beginning or during 
the course of the condition. The mental state is much stunted. The 
general growth of the body is retarded. The dwarfs are, however, 
well formed. The hands and extremities are perfect and the skin 
is not myxoedematous. 

Infantilism combined with lipomatosis may be confounded with 
cretinism. In this form of disease there is no myxoedema and the 
skin is very delicate and soft. The genitals are atrophied. The 
expression of the face is that of child-like simplicity, the forehead 
is low and narrow. The hair is dry, and does not grow ; the 
finger-nails do no grow. There may be, as in the case I published, 
blindness. The mental state is one of mild idiocy (Fig. 155). 

The treatment of cretinism constitutes one of the most marvel- 
lous chapters of modern medicine. The administration of thyroid 
extract results in a partial restoration of the mental capacity 
and a return to growth and development approaching the nor- 
mal. I published in 1897 some cases of cretinism diagnosed early 
in infancy, in which the treatment was begun at once. In those in 
which the treatment was begun at the age of one month, the chil- 
dren have become bright and apparently normal. In those in which 
it was inaugurated at the fifteenth month, the children have, after 
five years of treatment, remained somewhat backward in mental 
development. One patient, now a boy of six years, goes to school 
and recites his alphabet, but is very simple in manner. In these late 
cases the treatment does not give the complete results at first expected. 

I begin treatment by the administration of the dried extract, 
grain J (0.03) t. i. d., and increase the dose until the infant takes 
grain j (0.06) three times daily. After the symptoms have retrograded, 
the dosage is kept stationary for a few months. It is then reduced or 
the remedy is given only every other day. If symptoms, such as 
stupidity, pallor, or reduced temperature reappear, the dose is in- 
creased. The first sign of improvement is a reduction of the anaemia, 



696 



DISEASES OF THE THYROID GLAND. 



as evidenced in the increase of haemoglobin. The body temperature 
rises to the normal. The skin becomes of normal delicacy and supple. 
The stature increases and the hair becomes glossy. Thomson, of 



Fig. 155. 




Infantilism and lipomatosis universalis in a boy ten years of age. 

Edinburgh, has published cases of adult cretins whose bones became 
softened after the prolonged administration of thyroids. These were 
cases in which treatment was begun late in life. The symptoms of 
excessive administration of thyroids include rise of temperature and 
slight diarrhoea. 

I have found thyroid therapy of doubtful utility in cases of Mon- 
golian idiocy. In the dwarfs above mentioned, it causes increase 
of stature ; the intelligence, however, remains backward. 



DISEASES OF THE THYMUS GLAND. 697 

III. DISEASES OF THE THYMUS GLAND. 

Landmarks. — The thymus is a glandular organ enclosed in a 
capsule. It is situated in the anterior mediastinum, and contains in 
its structures a white tenacious fluid substance which is present in vary- 
ing quantities. Sappey shows that the thymus in the newborn infant 
extends from the upper edge of the manubrium sterni, 5 cm. downward. 
Its upper border may reach the isthmus of the thy roid or may be removed 
2 J cm. from it. It extends downward to the middle or upper third 
of the pericardium. In exceptional cases it may have a longitudinal 
diameter of 11 J cm., reaching the diaphragm (Triesethau). The 
thymus is about 2 to 3 cm. wide. Luschka makes it unsymmetrical, 
consisting of two lobes united by an isthmus. It lies over the 
course of the pulmonary artery and is surrounded by a reflection of 
the pericardium. It is separated from the sternum by loose con- 
nective tissue. Its length varies from 4 cm. in the nursling, to 11 
cm. in the ninth year, the average ratio to the body length being 1 
to 7 or 8. 

Weight. — Its weight varies. In the results which I obtained 
in collaboration with Jacobi, it did so within wide limits. In infancy 
the average weight is 20 grammes ; from the second to the fourteenth 
year it is 24 grammes. After the twenty-fifth year the thymus atro- 
phies and may weigh 2.2 grammes (Friedeleben). In abnormal 
states the weight may be 32 grammes (Triesethau, Pott). The 
causes of the enlargement of the gland and the conditions under 
which it occurs are not as yet known. The gland is large in infants 
dying of the most diverse diseases. 

Percussion. — Under the most favorable conditions it is difficult 
to ascertain the exact size. The thymus has sometimes been marked 
out as large during life, and post mortem found to be small. As a rule, 
an area of dulness situated behind the upper part of the sternum, and 
discernible on gentle percussion, may be cautiously interpreted as due 
to the thymus (Sahli). An unsymmetrical area giving dulness on 
one side of the sternum is probably due to the thymus (Luschka), 
especially in subjects under the second year. The thymus may be 
seen by a^-ray as a shadow behind the upper sternal region. 

Abnormal Conditions. — None of the abnormal conditions of the 
thymus can be diagnosed with certainty during life. 

Hypertrophy of the Thymus Gland, Including So-called 
" Thymus Death." 

Simple hypertrophy of the thymus gland, irrespective of its 
presence as a cause of sudden death, has been observed by Virchow, 
Grawitz, Jacobi, and others. It may exist without causing any 
symptoms, and only be discovered post mortem in children who have 



698 DISEASES OF THE THYMUS GLAND. 

died of various diseases. In other cases an enlarged or hypertrophied 
thymus has been described as causing a series of symptoms similar 
to what is seen in the adult subject in forms of asthma. Virchow, 
Grawitz, West, and Goodhardt have described such cases under the 
head of " Thymic Asthma." These cases are attended with par- 
oxysms resembling those of laryngismus stridulus with difficult 
breathing. Some of the cases described by the above authorities 
have eventuated in convulsions and sudden death. Recently Hoch- 
singer has attempted to revive the term ^' thymic asthma " as apply- 
ing to cases of laryngeal stridor ; the symptom-complex in such cases 
being due, in his opinion, to an enlarged condition of the thymus. 

There has been much discussion as to the existence of such an 
entity as '^ thymic asthma." 

There is another form of sudden death, the so-called " thymus 
death," which has been ascribed to hypertrophy of the thymus gland. 
These cases have been described by Yirchow, Grawitz, Pott, and 
others, and there seems to be a tendency in some quarters to attribute 
certain cases of sudden death to the existence of an enlarged thymus. 
In one case, described by Pott, the thymus weighed 32 grammes, was 
9 cm. long and IJ cm. thick. Cases of thymus death have been 
described, for the most part, in children who are the victims of a 
condition known as status lymphaticus. This condition should be 
differentiated from that described under the heading of Scrofulosis, 
and for the sake of clearness will be described under the head of 
Status Lymphaticus combined with that of thymus death. 

In the work of Jacobi it was shown that hemorrhages of the 
thymus are not uncommon, and are present in a number of conditions, 
especially in pertussis. Inflammation of the thymus may be present 
in inflammatory conditions of the pleura and pericardium. Steu- 
dener has published a case of sarcoma of the thymus, and Vogel one 
of carcinoma of that organ, occurring in childhood. Demme pub- 
lished a case of isolated tuberculosis of the thymus. In the mono- 
graph of Jacobi, general tuberculous infection of the thymus was 
investigated, as was also the condition as found in diphtheria. In 
the latter disease necrobiosis of the thymus was found as described 
by Oertel in other organs. Congenital syphilis may manifest itself 
in arterial and connective-tissue changes. Abscess of the thymus is 
rare. 

Status Lymphaticus. 

{Lymphatism ; Lymphatic Cowiiitution,) 

This condition is found chiefly in children who are subjects of 
rachitis and are moderately well nourished but ansemic. They have 
enlarged lymph-nodes at the angle of the jaw, in the axilla, and in 
the groin, and may have attacks of laryngismus stridulus. They 
have enlarged tonsils, adenoid tissue in the posterior nares, and en- 



THYMUS DEATH. 699 

largement of the adenoid tissue at the base of the tongue. On the 
other hand, they present none of the skin-, bone-, and joint-affections 
seen in the scrofulous or tuberculous subject. Escherich has pub- 
lished cases in which there were 30 attacks of laryngospasm a day. 
The patients also have symptoms of increased excitability of the 
peripheral motor nerves, such as Trousseau^ s phenomena and Chvos- 
tek^s symptom. I have had one case in which there was an attack 
of laryngismus at every crying-spell. The patients are in constant 
danger of sudden death. In rare cases in which sudden death has 
occurred an enlarged thymus has been found, and other lesions which 
will now be described under the title of Thymus Death. 

Thymus Death. 

There are two distinct sets of cases of sudden death in which the 
thymus has been found to be enlarged. The first are those in which, 
post mortem, absolutely no other change has been found than the 
presence of an enlarged thymus. In these cases the viscera were 
said to be absolutely normal, but, as has been stated elsewhere, there 
were evidences of lymphatism, such as enlarged tonsils, lymph-nodes, 
and solitary follicles in the intestine. 

The second set of cases is that in which the thymus was found 
not only to be enlarged, but apparently pressing on the trachea or 
arch of the aorta, causing complete obliteration of these organs. The 
latter set of cases were recorded by Beneke, Lange, and Weigert. 
But few of these cases published are to be considered in the category 
of thymus death, for these rather represent pathological growths of 
the thymus similar to any other tumor which might lead to pressure 
effects. Such a condition of the thymus is exceedingly rare. What 
interests the physician most, especially as the cause of sudden death, 
are the cases of enlarged thymus in which, as in the first set, no signs 
of pressure were found, either on the large vessels or the bronchi. 
That death in these cases is not caused by pressure is now generally 
conceded. The theory advanced by Paltauf and Escherich is not 
unreservedly accepted by all. Paltauf contends that the sudden 
death is due to an anomalous lymphato-chlorotic constitution, the 
enlarged thymus thus being only one of the manifestations of a gen- 
eral disturbance of nutrition, in which we also find enlarged lymph- 
nodes and tonsils, and hyperplasia of lymphatic tissue. Under 
the influence of this condition there are changes in the nerve-centres 
of the heart, as a consequence of which the least excitement may 
result in fatal paralysis. Escherich, in addition, while accepting 
this theory, thinks that in the condition of lymphatism there 
is an auto-intoxication whereby the nervous system is in a state 
of morbid irritability and instability which results in heart-syn- 
cope. In this condition the functions of the thymus are probably 



700 DISEASES OF THE THYMUS GLAND, 

disturbed, much like that of the thyroid in myxoedema or Basedow's 
disease. 

On the other hand, Richter, in a recent paper, which has been 
referred to in the section on Sudden Death, has analyzed all the cases 
published of the so-called thymus death. In most of these cases, 
in his opinion, there were present anatomically other conditions, such 
as bronchitis, intestinal cataarh, or some other disease, to account for 
the fatal issue. In most children overtaken by this form of death 
there is a condition of lymphatism, and this, in addition to the grow- 
ing thymus, which at the age of two years is quite large, has been 
made accountable for the death of these infants and children, whereas 
close study will always reveal some other morbid condition fully 
equal to causing this issue. 

Thymus death is one of the rarer forms of sudden death in early in- 
fancy, as compared with other forms. I have seen it twice, and know 
of nothing more distressing than such an occurrence. The physician 
may be examining such a child for a slight ailment, when suddenly 
the infant throws the head backward, there is a noiseless or snappy 
inspiration, the eyes turn upward and sideways, the pupils dilate, 
there is cyanosis both of the face and tongue as the latter becomes 
swollen and caught in the jaw ; there is a convulsive contraction of 
the body backward. There are several inefficient, noiseless, shallow 
inspiratory movements, the body then relaxes, the face becomes ashy 
pale, and the infant, within one or tw^o minutes, is dead. The 
heart ceases to beat at the beginning of the attack. It is really a 
syncopal death. 

There is another form of death in lymphatic infants and children 
which occurs in chloroform narcosis. In such cases the heart may 
suddenly cease to beat during the narcosis ; or, as in one of my cases, 
the child may have withstood the narcosis, though it was noticed to 
have taken the chloroform badly. Twelve hours after the operation 
— which in this case was one of appendicitis — the temperature rose 
slightly, there was a rapid increase in the heart action, the pulse 
mounting in a short time so that it could no longer be counted ; while 
the heart beat at the rate of over 200 a minute (cardiac paralysis) ; 
the pulse could not be felt at the wrist. Death occurred with all the 
signs of paralysis of the cardiac ganglia. 

In the case last described the child was extremely lymphatic, had 
a thymus enlarged to percussion, and a year previous had been oper- 
ated on for adenoid vegetations and enlarged tonsils. The lymphatic 
nodes throughout the whole body were enlarged. The appendicitis 
from which the child suffered was one of the mild catarrhal type. 
There was no septic peritonitis. 

Treatment. — Inasmuch as death supervenes in these cases before 
anything can be done in an orderly way, it is almost superfluous to 



DISEASES OF THE SPLEEN. 701 

speak of treatment. Pott, however, and others have performed 
tracheotomy in these cases with a view not only of relieving the 
spasm of the glottis, which in some instances is present, but of per- 
forming artificial respiration. Others have intubated. In those 
cases in which the heart has ceased to beat, we can scarcely expect 
to revive its action. In one case of a lymphatic child in which the 
heart failed at the outset of the chloroform narcosis, became irregular, 
and threatened to stop beating, artificial respiration, the Laborde 
method of resuscitation, and massage over the cardiac area according 
to the method described by Maas, brought the child to life again. 
We will not always succeed in this manner. 

The treatment of the general condition — the status lymphaticus 
— consists in the removal of the enlarged tonsils and adenoids. In 
these cases the condition of the lymphatic-node enlargements is vastly 
improved by the operation. Good food, cod-liver oil, and the prep- 
arations of the iodide of iron are also indicated. 

IV. DISEASES OF THE SPLEEN. 

Anatomical. — At different periods of childhood the length of 
the spleen varies from 4 to 10 cm., the breadth from 2 to 5 cm., 
the average thickness being about 0.5 cm. It forms an oval-shaped 
body, behind the ninth, tenth, and eleventh ribs, the long axis running 
in the direction of the ribs. Up to the second month of life, the an- 
terior edge of the spleen is found in the midaxillary line ; after that, 
it may be found further forward than this line, or posteriorly to it. 
The upper edge corresponds to the upper edge of the ninth rib ; the 
lower border to the lower border of the eleventh rib. The spleen 
may be located by percussion and palpation. 

Percussion. — The patient is caused to lie on the back. It is not 
necessary to cause children to lie in an inclined lateral posture. 
The upper border is first located by percussing from above down- 
ward in the midaxillary line on the left side. At the seventh rib 
is a strip of slight dulness extending from the seventh to the 
ninth rib. I have been able to locate it in infants and in chil- 
dren under the age of six years. There can be no question as to its 
existence, although there may be doubt as to its causation. Symming- 
ton, in his frozen section, shows that, in a girl six years of age, the left 
lobe of the liver is distinctly on the left side behind the seventh and 
ninth ribs. Sahli ascribes the strip to what he calls the deep dulness 
of the spleen. From the ninth rib downward, there is absolute 
dulness, then flatness, due to the presence of the spleen proper 
behind the chest wall. The anterior border of the spleen is located 
by percussing in a horizontal direction toward the axillary line along 
the tenth rib. 



702 DISEASES OF THE SPLEEN. 

Palpation. — The enlarged spleen can be distinctly made out 
by palpation. The abdomen should be relaxed. It is sometimes 
necessary to flex the thighs slightly, in order to relax the abdomen. 
In young infants it is not necessary. 

The physician stands at the right side of the patient and with the 
palmar surface of the fingers of the right hand palpates the abdom- 
inal parietes just beneath the border of the ribs (Fig. 156). As the 
patient inspires deeply, the hand is by steady pressure insinuated be- 
neath the ribs in an upward and backward direction. In the vast 
majority of cases under the tenth year, the normal spleen may thus 
be felt. 

In practice, it may safely be said that a spleen which cannot be 
felt below the border of the ribs is not enlarged, unless some con- 
dition, such as the presence of fluid or tympanites, prevents thorough 
palpation. I have rarely failed to palpate the enlarged spleen 

Fig. 156. 




Method of palpating the spleen. 

satisfactorily. Enlargement of the spleen is found in rachitis, 
chronic gastro-enteritis, sepsis, typhoid fever, malarial fever, vari- 
cella, syphilis, anaemia infantum pseudoleuksemica, leukaemia, Hodg- 
kin^s disease, congenital syphilis, cirrhosis of the liver, amyloid 
degeneration, heart disease, and simple catarrhal jaundice. 

From these statements it will be seen that enlargement of the 
spleen in infancy and childhood is pathognomonic of no one disease, 
and should not lead to any one conclusion. It is only corroborative 
in the presence of other signs and symptoms. Without a very 
thorough and painstaking examination of the blood, the significance 
of the enlarged spleen in the febrile and afebrile affections cannot 
be determined. In enlargements of the spleen such as are met 
in rachitis, heart disease, syphilis, chronic gastro-enteritis, icterus, 
varicella, examination of the blood may not be necessary. 



THE BLOOD IN INFANCY AND CHILDHOOD. 703 

Splenic and Kidney Tumors. 

In rare cases in which sarcoma of the left kidney is suspected, 
it may be necessary to exclude tumor of the spleen. 

An enlarged spleen is smooth on the surface and has a sharp 
anterior edge interrupted by an indentation — the hilus. The tumor 
is pointed and sharp below. It can be grasped deep in the lumbar 
region behind. 

Kidney tumors are irregular on the surface and marked out into 
lobes, some of which may be cystic. The tumor projects upward 
behind into the lower part of the chest. The whole lumbar region 
is flat on percussion. The borders of the tumor are rounded. On 
the other hand, I have made an autopsy in a case of cirrhosis of the 
liver and spleen in which the latter organ during life showed 
uneven tumors on its surface (gummata). The physician must 
be partly guided by the history of a case. The urine should be 
examined in cases of sarcoma of the kidney, and the blood in cases 
of enlarged spleen. I have seen a subphrenic abscess displace the 
spleen downward. The left lobe of the liver was also displaced 
in the same direction. Under ansesthes'ia, a round mass could be 
felt above the spleen, which was enlarged. Behind, the lung came 
well down to the bottom of the chest, as was evinced by the presence 
of the respiratory murmur. Dulness was, however, present in the 
left axillary line and behind. On exploratory puncture in the poste- 
rior axillary line, the subphrenic abscess was found to be present. 



V. DISEASES OF THE BLOOD. 

Leading General Characteristics of the Blood in Infancy 
and Childhood. 

For diagnostic purposes, it is important to bear in mind certain 
characteristics of the blood in infancy and childhood. Ehrlich has 
shown that conditions normal to the blood in early life are of grave 
import if found in the adult. 

The Red Blood-cells — the Erythrocytes. — During the first three 
days of life, nucleated red blood-cells are found in the normal blood. 
In the newly born infant, the red blood-cells number from 4,500,000 
to 6,500,000 to the cubic millimetre (Hayem). There is a polycy- 
thsemia. This condition is found during the first few days of life. 
On the fourteenth day there is an average of 5,500,000 red blood- 
cells to the cubic millimetre. From the second to the tenth year 
the average number is 5,000,000 (Otto, Schiff*, Sorenson). The 
polycythgemia in the newly born infant is greater if the tying of 
the umbilical cord is delayed until its pulsations cease. Weaklings 



704 DISEASES OF THE BLOOD. 

show a diminished number of red blood-cells. In addition to 
imperfect nutrition, anaemia of any kind, acute or chronic cachexia, 
and certain drugs, such as antipyrin, antifebrin, phenacetin, and 
lactophenin, reduce the number of red blood-cells by disintegrating 
a certain proportion of them (Monti). Infectious diseases, such as 
malaria, scarlet fever, typhoid fever, and sepsis, have a similar 
influence. In severe anaemia, such as that accompanying rachitis, 
nucleated red blood-cells appear in the blood. These are also 
found in the severe primary anaemias, in acute leukaemia, and 
in pernicious anaemia of infants and children. 

The White Blood-cells — the Leucocytes. — The number of 
leucocytes in the newly born infant is high, being from 18,000 to 
30,000 to the cubic millimetre (Hayem, Guppen). It gradually 
falls to 12,000 to the cubic millimetre, the average for infants. 
The percentage of lymphocytes is at first small in comparison with 
that of the poly nuclear leucocytes. Gundobin, whose work has been 
confirmed by Carstanjen, found that the polynuclear leucocytes pre- 
ponderate in the newborn infant. They increase and reach their 
highest figure in the first forty-eight hours of life. They then 
diminish in number, while the mononuclear lymphocytes increase 
proportionately until the seventh or tenth day, when the blood 
assumes the characteristics which distinguish it during the period of 
infancy. During infancy the mononuclear lymphocytes are more 
numerous than the polymorphonuclear leucocytes. The following 
table is taken from Gundobin' s figures : 

Polymorpho- 
nuclear Mononuclear Transitional 
leucocytes. lymphocytes. forms. 

Immediately after birth . . 63 per cent. 25 per cent. 12 per cent. 
Forty-eight hours after birth. 70 " 21 " 19 " 

Infancy 34.6 " 59 " 6.4 " 

In normal infants and young children, the number of leucocytes 
to the cubic millimetre may vary from 13,000 to 20,000 (Japha). 
The so-called digestive leucocytosis found in the adult is inconstant 
in infants and young children (Japha). There is undoubtedly an 
inflammatory leucocytosis in infants and children similar to that 
seen in the adult. It occurs in pneumonia, scarlet fever, rheu- 
matism, sepsis, diphtheria, post-hemorrhagic anaemia, and cachexia 
(sarcoma). In the normal state, the leucocytes may reach a mini- 
mum of 6000 to the cubic millimetre (Monti). This fact should be 
borne in mind in estimating the leucopoenia in typhoid fever, malaria, 
tuberculosis, and in other infectious or toxic states. 

The transitional forms of leucocytes are- numerous in the newly 
born infant, reaching their maximum from the sixth to the ninth 
day. The eosinophiles are present in the same number as in later 
life (Japha). 

The Haemoglobin. — The blood is richer in haemoglobin at birth 



ANEMIA. 705 

than later in life (Morse, Leichtenstern, Eotch). After birth 
the percentage of haemoglobin sinks, and at the third month 
reaches that of later life. Carstanjen found the hsemoglobin on the 
average 100 per cent, up to the twelfth day. The lowest percentages 
are found from the sixth month to the second year. There is, in 
exceptional cases in normal children, a very high percentage from 
the fifth to the tenth year, ranging from 95 to 110 (Widowitz, 
Leichtenstern, Hock, and Schlessinger). The percentage in healthy 
children may be as low as 60 (Fleischl) or 8.4 grammes to 100 c.c. 
of blood. At the third month of infancy it may range from 69 to 
94 ; up to the second year it may range from 62 to 81 (Monti). 
There seems to be no fixed normal limit. Ansemia or toxaemia 
of any kind and infectious diseases diminish the haemoglobin. 

The Specific Gravity. — The exact clinical significance of the 
specific gravity of the blood is little understood. The specific 
gravity is high in the newly born infant, ranging from 1.056 to 
1.066. From the sixth month to the tenth year it varies from 
1.050 to 1.056 (Monti). These figures correspond to those of 
Hock, Schlessinger, Lloyd, Jones, and others. The blood of strong 
children and breast-fed infants has a higher specific gravity. Diar- 
rhoea may raise it, but rarely to a ratio of more than 0.004 part per 
1000. The specific gravity is increased in the infectious diseases, 
pneumonia, pleuritis, endocarditis, typhoid fever, and tuberculous 
meningitis, and falls on the decline of these processes. It is also 
increased in congenital heart disease, chorea with endocarditis, icterus, 
and diphtheria. It diminishes with the loss in weight accompanying 
anaemia and nephritis, and in cachexia (Hock, Schlessinger, Monti, 
Hammersley, and Felsenthal). 



Anaemia. 

Anaemia is a condition resulting from a deficiency in the blood of 
one or more of its constituent elements. It may be either congenital 
or acquired. In the latter case it may either be secondary to other 
conditions or occur as a primary disease. Congenital anaemia is 
seen at birth in infants born of badly nourished mothers, who dur- 
ing pregnancy have suffered from some disease of the placenta, or 
from syphilis, tuberculosis, or malaria. The foetus in utero becomes 
anaemic. Acquired anaemia appears after birth. It is either sec- 
ondary to some acute loss of blood (post-hemorrhagic), to chronic 
loss of blood, or is caused by defective nutrition, unhygienic sur- 
roundings, diseases of the various organs, toxaemia, infectious diseases, 
or parasites. 

Primary or essential anaemia is the form in which the changes in 
the blood play so important a role that it is assumed there is a dis- 

45 



706 DISEASES OF THE BLOOD. 

ease of the blood itself or of the blood-formiDg organs (Monti). 
Such are the forms of leukaemia, chlorosis, and pernicious anaemia. 

Simple Anaemia. 

( Secondary A ncemia. ) 

Secondary simple anaemia may follow some acute or chronic loss 
of blood. In acute post-hemorrhagic anaemia, the increase of fluid 
elements keeps pace with the loss of blood if the loss, though small, 
is repeated at short intervals. Children show the effects of loss of 
blood much more quickly than adults. Hydraemia is the condition 
which results when the loss is marked. The fluid elements increase, 
and there is a diminution in the specific gravity of the blood and in 
the amount of haemoglobin. Hydraemia may result in children with- 
out hemorrhage ; that is to say, it may occur in extreme severe 
anaemia secondary to some disturbance of nutrition or to illness. In 
post-hemorrhagic anaemia the coagulability of the blood is increased 
immediately after the hemorrhage. Ehrlich supposes this to be due 
to an increase in the number of blood-plates. After the hemorrhage, 
the regeneration of blood is in the infant, as in the adult, indicated 
by the formation or appearance in the blood of microcytes, megalo- 
cytes, and nucleated red blood-cells (normoblasts). The severe forms 
of this variety of anaemia also show polychromatophilic properties of 
the red blood-cells. These are so poor in haemoglobin that with 
various stains the normal reaction is very much changed. There are 
various shades of the stained red blood-cells. In recent and severe 
cases of post-hemorrhagic anaemia there may be leucocytosis. There 
is an increase of the polynuclear neutrophilic leucocytes (Monti, 
Ehrlich). Nucleated red blood-cells (normoblasts) may appear in 
severe cases. Poikilocytosis is also one of the changes seen in the 
blood. 

Secondary anaemia of a mild or of a severe type is also seen in 
infants and children who sufler from defective nutrition. It com- 
plicates or accompanies rachitis, syphilis, scrofula, tuberculosis, gastro- 
intestinal catarrh, chronic endocarditis, purpura, morbus Werlhofii, 
and infectious diseases. 

The symptoms of mild anaemia in infants and children do not 
differ materially from those of adults. The patient is pale and the 
mucous membranes have a characteristic pallor. The appetite is capri- 
cious. The patients also suffer from symptoms due to the primary 
affection — syphilis, rachitis, acute infectious disease, gastro-enteric 
disturbance (acute or chronic), or cardiac affection. The pallor of 
cardiac disease or nephritis is characteristic in infants and children, 
as in the adult. 

The anaemia if of a severe type takes the hydraemic form. In 
the severer forms of anaemia, especially in infants and very young 



CHLOROSIS. 707 

children who suffer from syphilis or rachitis, the skin is waxy white 
or yellowish. The ears are absolutely devoid of any color of 
blood. In cretinism the skin has a greenish-yellow hue. Infants 
do not show the symptoms, such as dyspnoea or palpitation, seen 
in older children on exertion. The muscles are flabby and there 
is a disposition to lie quietly in the crib. The spleen may be 
large, and the liver also, especially if rachitis or syphilis is present. 
In cases in which the anaemia is extreme, the spleen may be 
normal. 

Infants and very young children do not always show the ansemic 
murmurs which are heard over the heart area in older children. In 
older children murmurs of that variety may be present with a 
venous hum in the neck, and the symptoms of mild and severe 
anaemia are essentially those of later life. These are indisposition 
to exertion, feelings of weakness, drowsiness, lack of appetite, irri- 
tability, and restlessness. Some of the severe forms of anaemia show 
for weeks a very slight irregular febrile curve. In many cases the 
fever is due to intestinal toxaemia. 

The Blood. — The mild forms of simple anaemia may show only 
a diminution in the amount of haemoglobin, a very slight diminution 
in the number of red cells, a reduction of the specific gravity, and if 
there is a primary affection which, like pneumonia, causes an increase 
in the number of leucocytes, leucocytosis. My records of severe 
forms of anaemia in infants and young children show a diminution 
in the amount of haemoglobin (18 per cent.). The blood shows 
microcytes, megalocytes, megaloblasts, and normoblasts. Increase 
of mononuclear lymphocytes is proportionate to that of the poly- 
nuclear leucocytes. Poikilocytosis in various forms is present, as are 
also polychromatophilic phenomena. In the severe forms of anaemia 
due to malarial poisoning I found, in addition to the plasmodium, 
microcytes, megalocytes, and megaloblasts. The eosinophils are not 
increased. In severe anaemia, the physical characteristics of the blood 
are striking. It may be so thin as to separate on puncture into 
a reddish and a colorless portion resembling beef-water. 

Chlorosis. 

Chlorosis is a form of primary anaemia. It is not a disease of 
infancy or childhood, and is mentioned here only in order to complete 
the classification of diseases of the blood. Its etiology is obscure. 
Yirchow believed it to be due to congenital narrowness of the 
whole arterial system and smallness of the heart. This theory 
does not explain the cases in which recovery takes place. Meinert 
ascribed the condition to an irritation of the abdominal sympathetic. 
Hofman thought that developmental conditions of the genital ap- 
paratus were causal in chlorosis. Forcheimer contends that intestinal 



708 DISEASES OF THE BLOOD. 

auto-infection is etiological in producing the chlorotic state, since 
there is in chlorosis an interference with the production of haemo- 
globin, the principal source of which is the gut. 

Occurrence. — Chlorosis is more common in females than in 
males, and occurs at the time of puberty. 

The condition of the blood has been described by Monti. The 
haemoglobin is diminished. The number of red blood-cells is in 
mild cases scarcely at all reduced. In severe cases it may fall to 
1,000,000 to the cubic millimetre. The absolute amount of haemo- 
globin may reach 4 to 8 in 100 cubic millimetres of blood. The 
specific weight may be reduced to 1035. There are microcytes in 
the blood. There is no leucocytosis. There are poikilocytosis and 
polychromatophilic appearances in the stained blood. 

Pseudoleuksemic Anaemia of von Jaksch. 

{Ancemia Lifantuia Pseudoleukcemica.) 

In 1889 von Jaksch described a symptom-complex met with 
among infants and young children, to which he gave the name of 
anaemia infantum pseudoleukaemica. He described the condition as 
a clinical entity which, in running its course, gives the picture of 
severe lymphatic anaemia. Tliere are enormous enlargement of the 
spleen, slight enlargement of the liver, some enlargement of the 
lymph-nodes, and changes in the blood. It is a secondary anaemia 
rather than a distinct disease. For this reason Fischl, Ej^stein, and 
others deny that it is a clinical entity. On the other hand, Monti 
and Luzet have described numbers of cases. I have records of 5 
cases, 1 of which was published. The anaemia is extreme. 

Etiology. — It is difficult to determine the etiology. Von Jaksch 
and Monti trace an intimate connection between this condition and 
rachitis. Wentworth and others regard it as secondary to some 
form of intestinal infection. 

Occurrence. — The condition is rarely found before the age of 
six months. My cases ranged from the ages of twelve to eighteen 
months. It may occur up to the third year, and is most common 
from the seventh to the twelfth month. Most of the cases thus 
far published have occurred in infants or children suffering from 
rachitis or congenital syphilis. In all of my cases there were signs 
of rachitis. Some of the children had previously suffered from 
chronic gastro-enteric derangement. 

Morbid Anatomy. — The spleen is large and fills the left hypo- 
chondrium, sometimes reaching the crest of the ilium. It is hard, 
smooth, and has a sharp border. There is an increase of the 
cellular elements. A small number of haemoglobin-bearing cells of 
the size of red blood-cells are found. 

The liver is slightly larger than is normal, but is of normal 



PSEUDOLEUKJEMIC ANEMIA OF VON JAKSCH. 



709 



consistency and color. The lobuli are less distinct than is normal. 
Luzet has described cellular elements in the liver containing finely 
granular protoplasm. These are not like liver cells. They have 



Fig. 157. 




Pseudoleuksemic anaemia, enlarged spleen and liver. 



small sharply defined nuclei, sacculated in shape. They are sur- 
mised to be forerunners of the red blood-cells. The liver cells are 
normal. The lymph-nodes are only moderately enlarged, and do 
not forui lymphomata, as is the case in leukaemia. There are no 
changes in the bone-marrow. 



710 DISEASES OF THE BLOOD. 

Symptoms. — The infants affected have as a rule suffered from 
chronic intestinal disturbances. Most of them are bottle-fed and 
atrophic. Although the skin is intensely anaemic and of a yellow, 
waxy tinge, there is sometimes a panniculus of fat. The musculature 
is flabby and the abdomen large. As a rule there are signs of 
rachitis. The fontanelle is open and the eruption of the teeth delayed. 
The infants are irritable, peevish, do not willingly take food, and do 
not assimilate it. In one of my cases, there was complicating pneu- 
monia. 

There is, as a rule, no fever, unless it is due to intestinal toxaemia. 
The picture is one of progressive emaciation and anaemia. In some 
cases there is complicating icterus, and the spleen reaches to the crest 
of the ileum. The edge of the spleen is sharp and the hilus can be 
distinctly felt. The liver is slightly enlarged ; its edge is round and 
smooth. In one of my cases, it extended two and one-half inches 
below the free border of the ribs (Fig. 157). The lymph-nodes in 
the groin and axillae are slightly enlarged, sometimes only to the 
size of a beau. 

The Blood. — The specific gravity of the blood is reduced. The 
haemoglobin may be reduced to one-quarter the normal percentage. 
It may be as low as 17 per cent. (Fleischl). There is a marked 
diminution of the number of red blood-cells. The nucleated forms 
of erythrocytes are abundant. There are megaloblasts, which show 
karyokinesis. In addition there are red blood-cells of all sizes — 
microcytes and megalocytes. There is poikilocytosis to a marked 
degree, and also polychromatophilia. The leucocytes are only 
moderately increased. In the severe cases the proportion of white 
blood-cells to the red may be as 1 : 100, 1 : 80, or 1 : 15 (Monti). 
The picture given by the leucocytes is different from that of leu- 
kaemia. Most authors agree that the various forms are represented 
and increased in equal ratio. In my cases, the mononuclear lympho- 
cytes, as well as the transitional forms, were increased. 

The course of the disease is chronic. In most cases, the chil- 
dren succumb to progressive weakness and emaciation, or to inter- 
current disease. Recovery may take place. I have seen one case 
of aggravated form improve under treatment. Whether these cases 
can, as stated by Monti, pass into a leukaemia or pernicious anaemia 
is a matter of doubt. 

Treatment. — Thus fiir the treatment has been empirical. Small 
doses of Fowler's solution are indicated. If rachitis is present, 
phosphorus is given by some in small doses. I have seen cases do 
badly under that treatment. Tonics and an easily assimilable diet 
are indicated. The bowels should be kept clear by enemata given 
daily in order to lessen the possibility of infection of the gut. 



LEUKEMIA (LEUKOOYTHuEMIA). 711 

Leukaemia (Leukocythsemia). 

Leukaemia is a persistent condition of the blood in which there is 
an increase of the white blood-cells, and a diminution of the red 
ones. It is a primary disease of the blood itself. Accompanying it, 
there are changes in the spleen, liver, bone-marrow, lymph-nodes, 
and lymphoid tissues. Virchow called the condition "white 
blood. ^' French writers have called it leukocythsemia. The pro- 
portion between the white and the red blood-cells is not so distin- 
guishing a feature as the appearance of large numbers of lympho- 
cytes in the blood, in which they are normally present in only small 
numbers. In one form the appearance of mononuclear neutrophile- 
staining myelocytes which are normally absent is a distinguishing 
feature. Ehrlich characterizes leukaemia as a mixed leucocytosis of 
chronic course, since white blood-cells of all kinds are present in 
the blood. This is not the case in the poly nuclear and eosinophile 
leucocytosis. 

Occurrence. — The disease is rare in childhood, but some 
authors believe it to be more common in the first year of life than 
is generally supposed (Monti, Mosler). Fifteen to 20 per cent, of 
the cases occur in the first decade of life (Baginsky). Males are 
more frequently affected than females. The disease is believed to be 
hereditary. 

The etiology of the affection is still unknown. In a few cases, 
micro-organisms and sporozoa have been found in the blood (Roux, 
Kelsch, Veillard, Lowit). The sporozoa of Lowit are described by 
him as being free in the blood as well as in the leucocytes and in 
the blood-making organs. In lymphatic leukaemia they are described 
as being intracellular only. 

Some writers think that rachitis and syphilis predispose to the 
development of leukaemia, especially if the bones are involved as 
well as the liver, spleen, and lymph-nodes. Certain forms of 
anaemia following malaria, diphtheria, and scarlet fever, and accom- 
panied by enlargement of the liver, spleen, and lymph-nodes, may, 
according to some writers, pave the way for leukaemia. Physical* or 
mental strain, unhygienic living, defective nutrition, and traumatism 
of the spleen, have all been regarded as predisposing factors. 

Forms. — The simplest classification of leukaemia is that based 
upon the anatomical appearances of the blood. Such is the classifi- 
cation of Ehrlich, which is as follows : 

(a) Lymphatic leukaemia, in which there is a marked hyper- 
plasia of lymphoid tissue. 

(6) Myelogenous leukaemia, in which there is hyperplasia of 
myelogenous tissue. Lymphatic leukaemia may run an acute or a 
chronic course. In both forms the distinguishing feature is the 
appearance in the blood of large numbers of the mononuclear lym- 



712 DISEASES OF THE BLOOD. 

phocytes and the displacement of the polynuclear leucocytes. The 
acute form is rare. It occurs in childhood. Six cases have 
occurred in my hospital service in the past four years. Its course is 
rapid. There are slight or marked tumor of the spleen, slight or 
very marked enlargement of the liver, and a tendency to petechise 
and to general hemorrhages. Some authors regard these cases as 
infectious. The chronic forms show marked enlargement of the 
spleen. 

Changes in the Blood. — As was previously stated, the lym- 
phatic forms of leukaemia are distinguished by the appearance, in the 
blood, of large numbers of the small and large mononuclear lympho- 
cytes. In the myelogenous forms, a cell which is normally not 
present in the blood, but is indigenous to the bone-marrow, appears 
in large numbers. This cell is the large mononuclear neutrophilic 
staining cell, the myelocyte of Ehrlich. The mast-cells are also 
found in these cases, but are not peculiar to this form of anaemia. 
In addition there is in the myelogenous forms of leukaemia an 
increase in the number of all three types of granulated white cells, 
the neutrophiles, the eosinophiles, and the mast-cells. There are 
dwarf forms of the white blood-cells, mitoses, and lastly large num- 
bers of nucleated red blood-cells. Normoblasts, megaloblasts, and 
myelocytes are not normally present in the blood. They are occa- 
sionally found in pneumonia, and in leucocytosis. The eosinophiles 
are increased to fifteen times their normal number. The slow 
coagulability of leuksemic blood is characteristic. 

The spleen is enlarged. It is at first soft, often firm, and is 
infiltrated with lymph-cells. The capsule is thickened ; the connec- 
tive-tissue stroma is increased and infiltrated with lymph-cells. The 
lymph-nodes show similar changes, and may be enlarged, forming 
tumors of considerable size. 

The bone-marrow is so infiltrated with lymph-cells as to acquire 
the appearance of a purulent infiltration. The same lymphoid infil- 
tration is found in the liver. The follicles of the gut are swollen. 
There is an increase of lymphoid cells and tissues. The lymphoid 
tissues elsewhere, such as the tonsils, thymus, skin, and even the 
retina, show the same changes. There are hemorrhages and exu- 
date in the ear, and the nerves and nervous tissue of the central 
nervous system are the seat of lymphoid cellular invasion. 

Symptoms. — Acute Leukaemia. — Cases of acute .leukaemia in 
infancy and childhood have lately been increasing in the literature. 
The most recent cases include those of McCrae, in a boy aged 
three years, and of Miller, in an infant of eight months. Cases 
have also been reported by Morse, Japha, Strauss, Monti, Berggriin. 
The symptoms in all the published cases were similar. In a boy eight 
years old, admitted to my hospital service, there were no premonitory 
symptoms. Two months before admission he was in good health. 



LEUKEMIA (LEUKOCYTHJEMIA). 



713 



He became very pale, there were irritability and loss of appetite, 
and the abdomen increased markedly in size. He complained of 
pains in the legs, and at the onset had chills and fever every other day. 
After the appearance of the chills he suffered from a low irregular 



Fig. 158. 




Acute lymphatic leukaemia. Enlarged lymph-nodes, spleen, and liver. Boy four and one- 
half years of age. 



fever. A week before death, the skin had a waxy color, there were 
petechise on the extremities, the gums bled easily, and the lymph- 
nodes of the axillse and groin were enlarged. There was an ansemic 
murmur with the first sound of the heart ; the liver was enlarged 
below the free border of the ribs to the extent of two fingers' breadth ; 
the spleen was enlarged to the level of the umbilicus ; the fundus 
of the eye showed retinal hemorrhages. Examination of the blood 
shoAved the haemoglobin to be reduced to 15 per cent. (Fleischl). 
The red blood-cells numbered 1,012,000 to the cubic millimetre ; 
the white blood-cells, 37,000. There was an immense prepon- 
derance of lymphocytes "(mononuclear). The patient died with 
signs of progressive weakness. Coma was preceded by vomiting 



714 DISEASES OF THE BLOOD. 

and the appearance of a few petechise. The blood state continued 
much the same as at first. In another case the number of mono- 
nuclear lymphocytes was fully 75 per cent, of the white blood-cells. 
In both these cases the spleen and liver diminished before death. 
The proportion of white to red blood-cells may not be far from 
normal. In another case the nucleated red blood-cells, large and 
small, were very numerous. In this case, in a boy of four and one- 
half years, the nodes around the parotid and angle of the jaw, in 
the axilla, and in the inguinal region, increased in a short time to a 
large size, and the spleen grew rapidly larger and reached to the 
crest of the ilium. The liver reached to the umbilicus. These 
mediastinal lymph-nodes were enlarged and caused great dyspnoea. 
The distress was very great just before the lethal issue (Fig. 158). 
In a case of v. Noorden's the proportion of the white to the red 
blood-cells was 1 : 200. The predominance of the lymphocytes is 
diagnostic. Most of the cases published showed a slight tempera- 
ture. The fatal issue usually results a few weeks or a month or 
two after the onset of symptoms. 

The Chronic Form. — The symptoms of the chronic form extend 
over a greater length of time. For months there are anaemia, lassi- 
tude, and extreme physical weakness. The appetite is good, but in 
spite of abundant nourishment, emaciation is progressive. In some 
cases there are periodic diarrliceal attacks. Profuse hemorrhage 
may occur without warning either from the nose or intestines. 
Chills and fever resembling those of paludism are sometimes present. 
None of these symptoms is particularly characteristic. As the dis- 
ease progresses there are headache and pain in the limbs and 
in the region of the spleen. The anaemia after a time assumes a 
severe type, and the skin becomes waxy and yellow. At this stage 
the spleen and liver enlarge and distend the abdomen. There 
are dyspnoea and palpitation ; the anaemia takes the hydraemic form, 
and there is oedema of the face, hands, and feet. Hemorrhages then 
occur from the nose, lungs, mouth, intestines, but rarely from the 
kidneys. There are petechiae in the skin and hemorrhages in the 
retina. In the lymphatic form the lymph-nodes in various parts of 
the body enlarge and form masses which are painless and covered 
with unaflPected skin. The skin may be affected by the process. 
The mesenteric nodes may sometimes be felt through the abdomen. 
The spleen attains an enormous size. The liver may extend as far 
as the umbilicus. Respiratory difficulties, heart weakness, and 
nervous symptoms (such as vertigo, somnolence, and coma) end the 
clinical course of the disease. The urine is diminished, and con- 
tains hyaline casts, lymphoid cells, and a trace of albumin. There 
may be a slight continued fever in the course of the disease. 

The prognosis is very unfavorable. Of 39 cases collected by 
Birch-Hirschfeld, only 4 recovered. Only in the early stage is 



THE HEMORnBAGlO DIATHESES. 715 

recovery possible. Death supervenes from exhaustion with hemor- 
rhages or from intercurrent pleuritis or pericarditis. 

The treatment of a disease whose exact nature is still unknown 
is difficult. Good food, and hygienic surroundings are the first 
requisite. In the treatment of anaemia, the iodide of iron, cod-liver 
oil, and arsenic are the chief drugs employed. In the lymphatic 
form, arsenic in the form of Fowler's solution gives the best results. 



Hodgkins' Disease. 

{Ancemia Lymphatica ; Adenie ; Pseudoleukodmia ; Lymphadenoma.) 

This disease is really not an affection of infancy and childhood 
inasmuch as 75 per cent, of the cases occur above the age of ten years. 
It is mentioned here to emphasize its characteristics as distinct from 
tuberculous adenitis or scrofulous enlargements of the lymph-nodes. 
It is an affection beginning with the enlargement of the lymph-nodes 
of the neck, usually of one side, and accompanied by an enlarged spleen 
and liver. In the spleen, liver, and other organs there are nodular 
growths. There is a progressive cachexia accompanied by febrile 
periods. The disease is fatal either in a short time of a few months or 
after a period of two or three years, during which there maybe intervals 
of improvement. There are no changes in the blood such as are seen 
in true leukaemia, and in this lies the main element of differential 
diagnosis. A most complete account of the nature of this rare affec- 
tion will be found in a recent monograph by Dr. Reed, published in 
the Johns Hopkins Hospital Reports, Vol. X., and in a monograph 
by Clarke in which he collected 43 cases. 

The Hemorrhagic Diatheses. 

In this class of diseases are embraced only those affections which 
are due to some primary change in the blood or in the circulatory 
apparatus. Thus conditions which are due to local disease of some 
organ, or the hemorrhages which follow the acute infectious diseases 
or drug poisoning are not included. Experimental pathology has as 
yet not given any clue to the etiology of the hemorrhagic diatheses. 
The contention of William Koch and Ajello, that they are infectious 
diseases or are due to some auto-intoxication, is not universally ac- 
cepted. At present the clinical classification of these diatheses into 
the transitory forms in which are included purpura simplex, peliosis 
rheumatica hsemorrhagica, scorbutus, and the persistent form heredi- 
tary in character, such as haemophilia, may be accepted. In the 
latter, the hemorrhage may be extensive, difficult to control, and due 
to some very slight cause. 



716 DISEASES OF THE BLOOD. 

Simple Purpura. 

This is a transitory condition characterized by small hemorrhages 
or petechias, or large, irregularly shaped extravasations of blood. 
These are as a rule discrete, but may be confluent, and are situated 
in the epidermis or in the superficial layers of the cutis. Imme- 
diately after the extravasation they have a bluish-purple tinge. After 
a few days they become brown or greenish yellow. These extravasa- 
tions are seen most frequently on the lower extremities, generally 
on the extensor surface. They also occur in other localities. As a 
rule there are few or no symptoms. There may be crops of petechise 
appearing at short intervals. In a few cases there are, after an exacer- 
bation of the local phenomena, loss of appetite, vomiting, and general 
malaise. The so-called purpura cachecticorum appears on the body, 
abdomen, back, and upper extremities in children under two years, 
suffering from diarrhoea and other exhausting diseases. In the latter 
case there may be leucocytosis, due to the original affection. The 
changes in the blood in simple purpura are still to be studied. 

Etiology. — The cause of this purpura is still unknown. It may 
be due to some obscure toxsemia. 

The prognosis is very good in the primary form. In the second- 
ary form it will depend on the nature of the original affection. 

The treatment will depend on the nature of the original disease. 
I treat the purpura itself in the same manner as cases of purpura 
hsemorrhagica, which will later be fully described. 

Haemophilia. 

Haemophilia is a rare condition which may be congenital or 
hereditary. It becomes apparent at birth or in early infancy, and 
is rare in later life. 

The nature of the affection is obscure. It is a type of hemor- 
rhagic diathesis which is transmitted from generation to generation 
in the female line. It is characterized by the occurrence of uncon- 
trollable hemorrhage after very slight injuries, and operations, and 
also in the absence of known traumatism. 

Etiology. — Many theories of the cause of the affection have been 
advanced. They may be grouped as follows : 

'a) An abnormal delicacy and friability of the bloodvessels. 

[b) An increase of the volume of blood (Immerman), 

(c) A defect in the coagulable constituents of the blood. 

(c?) Certain agencies acting as toxins on the elements of the 
blood, causing their dissolution (Koch). 

The condition is most common in the Slavic races. Children 
dying of the affection show evidences of intense anaemia, but may 
be well nourished. Virchow has demonstrated that there is a nar- 
rowness in the arteries and also a thinness of their walls. Birch- 



PLATE XXV. 




Haemophilia. Boy six years of age. Haematoma of the face ; 
hemorrhage into the knee-joint. (Case of Dr. Martin Ware.) 



PURPURA HEMORRHAGICA, 717 

Hirschfeld found that the eDdothelium of the arteries was enlarged, 
and that the nuclei were swollen. The blood itself shows no 
changes except those proper to post-hem orrhagic anseraia. The 
hemorrhages may occur in any region and from any organ of the 
body. There may be hemorrhage into joints, profuse epistaxis, 
intestinal hemorrhage or uncontrollable hemorrhage from the mouth 
or lung. The drawing of a tooth, the incision of an abscess, or a 
minor operation such as circumcision, may cause uncontrollable and 
fatal hemorrhage. l\\ the newly born infant, there may be fatal 
hemorrhage from the cord. In the case pictured in Plate XXV. 
there were hemorrhages into the joints and into the face, without 
distinct traumatism. This case came of a family of bleeders in 
which there had been fatalities following circumcision. 

The condition lasts weeks, months, or years — in fact, it persists 
during the life of the individual. Some authors believe that the 
female members of families thus affected should not marry. 

The treatment is mainly prophylactic. The infant should 
nurse a wet-nurse, in order that the noxious influence of its own 
mother\s milk may be lessened. Good food and fruits of all kinds 
should be given. All operations and traumatism should be care- 
fully avoided. 

Purpura Hsemorrhagica. 

{Morbus Maculosus Werlhofii.) 

In the prodromal period before the appearance of the hemor- 
rhages, there may be several days of general malaise, disturbance of 
appetite and digestion, and febrile movement. There are anaemia, 
pain in the limbs, and oedema of the feet. The hemorrhages may 
appear without any symptoms. They are especially frequent in 
the lower extremities, and next most frequent in the upper extremi- 
ties and on the chest, face, and trunk. They consist of extrava- 
sations of blood in the skin and subcutaneous tissue. The mucous 
membranes are frequently affected. Epistaxis, bleeding of the 
gums, bloody movements, and bloody urine result. There are 
ecchymoses in the conjunctiva and bleeding from the ear. The 
hemorrhages in the skin may be petechise, or irregular bluish or 
purple blotches which subsequently become yellowish or greenish 
yellow. They occur spontaneously or follow slight traumatism or 
pressure. There may be hemorrhages into the joints. There may 
be exacerbations and recurrences of hemorrhages extending over 
weeks. The tendency of the mucous membrane to bleed has been 
mentioned. The gums are spongy and bleed easily. There are 
hemorrhages or petechise on the soft and the hard palate. The 
hemorrhages from the kidney cause the appearance of albumin 
and blood in the urine. The urine is red and blood-coloring 



718 DISEASES OF THE BLOOD. 

matter may be found by the turpentine-guaiac test. Hcmorrliages 
in the brain and eentral nervous system may oeeur, causing paralysers 
and (;oma. In mild cases then^ is no disturbancH^ of nutrition, but 
in severe ones the uraemia is marked, as is also the emaciation. 
The blood shows few changes. The number of red blood-cells is 
diminislied, as is also the specific gravity. In severe cases there is 
a slight leucocytosis ; the ])olynu(;lear leucocytes are inci;eased, 
(M)sinoj)hiles are few, mierocytes are ])resent, and then* are a few nor- 
moblasts, '^l^he leucocytosis iin[)r()ves as recovc^ry sets in. 

Course. — The cases of ordinary severity recover. Severe cases 
may recovei- or may result fatally. 

The etiology of this aileetion is still obscure. r>e(^ause of its 
infectious nature, Willinin Koch believes it to be allied to sciorbutus 
and other hemorrhagic affections. His view is not suj)})()rted by 
other writers. Ajello and Schwab regard the condition as an auto- 
infection or a form of toxaemia. Kolb, Tizzoni, and Babes have 
found bacteria in the blood of fatal cases. Otlu^rs have isolated 
str(^ptoco(XM and staphylococci from the blood (Lebreton). In one 
of my cases then^ was a history of an insect-bite. The disease is 
rare in breast-fed infants and is more common after the age of two 
years than before. The infants and children attacked may have 
previously been in good health. 

Th(5 diagnosis is made from the (bourse of the affection and the 
size; and natui'c! of the hemorrhages. The constitutional disturbance 
is more markcnl than in simple pui'pnra. The hemorrhages ai*c 
blot('JK\s, in that respect dilfering from the pelcchia* of peliosis. 
TIk! joints ai'(^ not swolkui, as in the latter affection. 

The treatment consists in ])la(;ing the patient in hygienic sur- 
roundings, and giving a nutritious diet with a liberal allowance of 
frnit and vegc'table aeids. In marked (;ases, Fowler's solution, 
given in nioderalc doses, gives good results. 

Purpura Rheumatica. 

{Pc/ioniti RhcnvuUlca of Schdnlein.) 

Purpura rheumatica consists of an eru])ti()n of small discrete 
|)ur|)uric spots in the vicinity of the large joints of the extremities, 
and o(u*,un-ing espec^ially on the lowc^r extremities above the knee. 
'I'he accompanying symptoms nrv. ])Min and swelling of tlu^ joints 
of th(^ lowei- or upper extremities. 

Symptoms. — Slight fever is followed by tlu^ appearance of the 
])urpuri(^ spots and the swelling of the j<m)ts of the lower and rarely 
of the up])er extremities. The joints are piiinful, as in rheumatism. 
At times the swelling of the joints is less apparent, but there is 
nevertheless tcniderness on pressui'e. Tlu^ purpuiM(i sj)ots are ])artic- 
ularly numerous in the vicrinity of the joints. A genend urticaria 



HENOCH'S PURPURA. 719 

may precede the appearance of the purpura. There are no heart 
complications. The condition of the blood is not as yet understood. 
There may be several crops of purpuric spots appearing at intervals 
of days or weeks. In other cases there are oedema of the face and 
enlargement of the spleen. In one of my cases there were at first 
slight hemorrhages from the bowel. There may be epigastric pain 
and tenderness in the course of the disease. 

The average duration of the affection is from ten to fourteen days. 
There may be relapses extending over weeks. 

The etiology is obscure. The disease occurs in children pre- 
viously healthy. It is seen in older children only, and has no ap- 
parent relation to acute articular rheumatism. 

The prognosis is good even when there are several relapses and 
when the affection takes a subacute course. 

Treatment. — Rest in bed is the first requisite of treatment. A 
nutritious diet in which there is an abundant allowance of fruit and 
vegetable acids is given. Lemonade and orange-juice are especially 
indicated. The bowels are regulated with the salicylate of sodium 
given in moderate doses. A child four years of age is given grains 
v (0.3) three times daily. The pains in the joints are easily con- 
trolled by rest. In the subacute stage small doses of Fowler's 
solution are of great benefit. 

Henoch's Purpura. 

Henoch in 1874 described a series of 4 cases of purpura which he 
classified as distinct from purpura hsemorrhagica orpeliosisrheumatica. 
The symptoms were as follows : Children apparently in good health 
were attacked by a form of purpura in which there were arthritic 
pain, vomiting, and intense abdominal pains with bloody diarrhoea. 
The rheumatoid pains were accompanied by swelling of the joints. 
The purpura was of the hemorrhagic type — that is to say, there 
were extravasations of blood in the form of ecchymoses or raised 
exanthematic areas, not disappearing on pressure. The areas were 
situated on the abdomen and lower extremities. The joints affected 
were those of the wrist, elbow, and ankle. The intestinal symptoms 
consisted of repeated vomiting, tympanites, excruciating colicky 
pains, bloody stools, and tenesmus. One case was fatal. Such 
cases have been from time to time described by other observers. I 
have seen a number of cases. These cases are at present regarded as 
due to a form of intestinal infection the exact nature of which is still 
obscure. They constitute a group probably belonging to the class of 
primary hemorrhagic affections in which is included the so-called 
peliosis rheumatica. 

Diagnosis of Forms of Purpura. — It is not always possible, 
clinically, to assign each form of purpura to its proper class. This 



720 BISEASES OF THE BLOOD. 

is especially true with young children, in whom there occur forms 
of purpura showing a diversity of symptoms and not fitting into 
any sharply defined class. Nor is it always possible at the bedside 
to decide whether the condition present is scorbutus or idiopathic 
purpura. Characteristic of both purpura and scorbutus are the 
hemorrhages into the skin, the internal organs, the serous cavities, 
and the mucous membranes. On the other hand, the frequency of 
hemorrhages and affections of the gums, the prodromal cachexia, 
the joint-affections, and the periosteal hemorrhages are peculiarly 
characteristic of that form of scurvy called Barlow's disease, which 
is seen in nurslings and young children. The purpuric affections of 
so-called idiopathic type, in which a purpuric exanthema is spread 
over the whole surface, may be called simple purpura. 

In the so-called rheumatic purpura or peliosis rheumatica there 
is a blotchy hemorrhagic exudate over the surface in the vicinity 
of the joints, with pain in the joints, and gastric pains. There is 
always a tendency to relapses. Hemorrhages from the mucous 
membranes and bowels are rare, but occasionally occur. 

In purpura hsemorrhagica or morbus Werlhofii there are minute 
or blotchy hemorrhages in the skin and internal hemorrhages from 
the mucous membranes, stomach, and intestines. Attempts to 
define sharply each of these sets of cases have been made. It is 
not always possible or desirable to do so. I have seen cases of 
peliosis with bowel hemorrhages and gastric crises, and cases of 
purpura hsemorrhagica in infants, in which there were pains in the 
joints, evinced by the distress shown when the joints were moved. 
The forms of purpura regarded by Henoch as a distinct type are 
classed by others as purpura rheumatica. The different classes of 
idiopathic purpura therefore overlap, one case frequently showing 
symptoms of two types. The only possible conclusion is that there 
may be a common cause of all forms of purpura — probably an in- 
fection. 

Pernicious Anaemia. 

This is a primary anaemia which causes progressive impoverish- 
ment of the blood and results in death. It is not common in 
infancy and childhood. The condition of the blood in infancy and 
childhood has not as yet been closely studied. The changes in the 
blood which have been published as characteristic of this condi- 
tion in infancy and childhood are found in other states, such as the 
severe anaemia of rachitis and syphilis. Ehrlich is not disposed to 
accept these cases without question. Blood pictures which in the 
adult may be diagnostic of pernicious anaemia cannot be thus in- 
terpreted when found in infants and young children. Observers 
of note, such as Monti, Berggriin, and Baginsky, have published 



INFANTILE SCORBUTUS OR SCURVY. 721 

cases in infants and young children. I have met- a case in an 
infant which had been bitten by a rat. After an interval, anaemia 
of a progressive and fatal type set in. The changes in the blood 
were similar to those characteristic of the same form of anaemia in 
the adult. Monti has collected 16 cases, 2 of which were in in- 
fants ; 5 ranged from one to six years ; 9 were above the age of 
five years. On the other hand, Ehrlich found that of 240 authentic 
cases, only 1 occurred in the first decade of life. That case was in a 
girl of eight years. In the face of such great diversity of opinion, it 
is wise to await the results of further research. For the purpose of 
reference, the following account of the changes in the blood which, 
according to Ehrlich, are diagnostic of pernicious anaemia in the 
adult, is appended : 

(a) The volume of blood is markedly diminished. 

(6) The color is at first normal, but later resembles that of beef- 
water. 

(c) The haemoglobin may be as low as 10 per cent. (Fleischl). 
This is due to a diminution of the number of red blood-cells, for 
the individual cell may have a haemoglobin content equal to the 
normal or above it. 

(d) There are microcytes, megalocytes, and sometimes giganto- 
cytes. The megalocytes may constitute 70 per cent, of the red 
blood-cells. They become fewer on convalescence. There are few 
megaloblasts, but characteristic normoblasts are found. 

(e) Clumps of free granules are found in the blood. The red 
blood-cells may contain granules. 

(/) Staining solutions produce polychromatophilic effects. 

(g) The eosinophiles are normal in number. 

(h ) The number of white blood-cells is diminished as well as 
that of the polynuclear neutrophiles. The latter condition indicates 
serious involvement of the bone-marrow. The lymphocytes are 
proportionately increased. 

(^) The leucocytes show no changes. Improvement is ushered 
in by leucocytosis. 

(j) The specific gravity of the blood is diminished, as is also its 
coagulability. 

In my case the nucleated red blood-cells were numerous. 

Infantile Scorbutus or Scurvy (Barlow). 

{Acute Rachitis (Moller) ; Barloiu's Disease, Hemorrhagic Rachitis {F^ust) ; Scurvy 
Rickets (Cheadle) ; Hemorrhagic Periostitis (Smith). 

History. — Cases of this affection are described in the literature 
under the name Acute Rachitis, which was given by Moller, 1859- 
1862. The first definite clinical description of the disease under 
its present title was made by Barlow, Cheadle, Gee, and others of 

46 



722 DISEASES OF THE BLOOD. 

the English school, completed its clinical stndy. Northrup and 
Crandall have made it familiar to American physicians. 

Occurrence. — The disease occurs chiefly in infants and in chil- 
dren under the age of two years. Under certain conditions it also 
occurs in older children and in adults. The majority of the 372 
cases collected by the committee of the American Pediatric Society, 
occurred between the sixth and fourteenth months. The ninth 
month show^ed the greatest percentage of the cases occurring before 
the end of the second year. The sexes were equally affected. A 
second attack was recorded in a case of Holt's. In a case which I 
saw recently, there were two attacks. 

The Nature of the Affection. — The nature of scurvy as it is 
seen in infants and children is still obscure. It is undoubtedly a 
form of hemorrhagic diathesis, which attacks subjects susceptible 
because of previous abnormal constitutional conditions and defective 
nutrition. There are several theories as to its exact nature. None 
is universally accepted. Some insist that it is a form of acute 
rachitis (M5ller, Forster, Bohm, Steiner, Fiirst, Ausset). Others 
contend that it is a form of scorbutus (Barlow, Northrup, Crandall, 
Netter, Rehn, Pott). Some of the English school regard it as a 
combination of scurvy and rickets (Cheadle, Gee, West). To the 
latter contention Heubner, Schoedel, and Nauwerck give most sup- 
port. These authors insist that the disease supervenes only in an 
organism already affected by slight or marked rachitis. On the other 
hand, there are authors who, like Schmorl and Naegeli, think that the 
affection is sui generis. Some authors have endeavored to establish 
a correlation with congenital syphilis. The consensus of clinical 
opinion, however, tends toward the acceptance of the theory of the 
scorbutic nature of the affection. 

Etiology. — The essential exciting cause is not yet known. The 
theory of the toxsemic or infectious nature of the disease has been 
advocated by William Koch. Bacteria of various kinds have been 
found in the blood, but there is little uniformity in the results of 
studies. In all the cases thus far studied the nature of the diet, 
breast-milk, raw cows' milk, sterilized or pasteurized milk, or some 
artificial food, has been a strong predisposing factor. The diet has 
been insufficient for the nutrition of the patient, but what special 
element has been lacking in the food is still obscure. In the collected 
results of the investigations of the American Pediatric Society 10 
infants were wholly breast-fed ; 2 were partially breast-fed ; 4 took 
raw milk. The greater number, 68, were brought up exclusively 
on sterilized milk ; 1 6 took pasteurized milk. The others took 
foods of different kinds. It may be that the mode of preparing the 
food (raw cows' milk, pasteurized or sterilized milk) is of less im- 
portance in paving the way for the onset of this affection than its 
inherent composition. Cases have been cured in part by changing the 



PLATE XXVI 




x-ray of the Bones of the Leg in a Case of Scorbutus, 
shoAA^ing the hemorrhage under and in the periosteum of 
the tibia at the junction of the middle and lower third of 
the bone. 



INFANTILE SCORBUTUS OR SCURVY. 723 

composition of the food, also by substituting sterilized for pasteurized 
food, and vice versa. The very fact that breast-milk has been the 
exclusive article of diet in some cases should direct attention to the 
fact that the affection may be caused by lack of some necessary 
element in the diet. This view is commonly taken at present. It 
is interesting in this connection to consider the contention of the 
celebrated Arctic explorer Nansen, that if exercise and fresh air are 
taken, and abstinence from alcohol is maintained, scurvy on voyages 
will be unknown if foods are carefully sterilized and devoid of toxins 
and ptomains. The latter, he insists, exist in most of the milk, fish, 
and food eaten on voyages. Although in the most aggravated cases 
of scurvy that have come under my notice the diet has been steril- 
ized milk, many infants who take that food prepared properly do not 
develop the disease. Some authors believe that the success of anti- 
scorbutic treatment with vegetable acids indicates that the organism 
has been for a time deprived of some essential food element. In the 
presence of a concrete case attention should first be directed to 
securing fresh food of proper composition. 

Rachitis. — Much has been said as to the connection of rachitis 
with this disease. The investigations above referred to show that fully 
45 per cent, of the cases occurred in infants and children who 
showed clinically signs of rachitis. This does not account for cases 
in which rachitis may exist, but may not be apparent except on 
microscopic examination (Hirschsprung, Schoedel). The majority 
of cases examined post mortem showed the changes of rachitis 
(Schoedel, Schmorl). 

The morbid anatomy has been carefully and extensively 
studied by Schoedel, Nauwerck, and Schmorl, whose results agree in 
all essentials. 

The bones in most cases show the changes seen in rachitis. 
There are disturbances of growth and of bone formation. There is 
an increase in the width and vascularization of the cartilage zone. 
There are irregularity of the calcification zone, and a pathological 
formation of osteoid tissue. The changes at the epiphyseal junc- 
tion and the periosteum are those seen in rachitis. The ribs are the 
bones most frequently aifected, the next greatest frequency being in 
the bones of the lower and upper extremities. The changes caused 
by scurvy consist of hemorrhages into the loose vascular layer of 
connective tissue of the periosteum adjacent to the bone. Thus the 
hemorrhages are intraperiosteal and subperiosteal (Plate XXVI.). 
They may be of considerable extent, either in the vicinity of 
the epiphyseal junction or in course of the shaft of the bone. 
They may form a layer several millimetres or centimetres in thick- 
ness. The outer layer of the periosteum, the fibrillar connective- 
tissue strata, is not the seat of hemorrhage except in the severest 
cases. The layer of periosteum next the bone is thickened. The 



724 DISEASES OF THE BLOOD. 

hemorrhages are both recent and old. Hemorrhages of both kinds 
are found in the medullary canal. The morbid changes are most 
marked in the ribs, next in the femur and in the bones of the upper 
extremities. Some of the long bones show loosening and even sepa- 
ration of the epiphyses and diaphyses. The infractures or fractures 
are of this nature. The fragments may override. In such cases the 
hemorrhage is great. The marrow of the bones loses its lymphoid 
character and becomes gelatinous. 

There are subpleural and subepicardial hemorrhages. The spleen 
is enlarged, owing to the presence of rachitis. Slight subcuta- 
neous hemorrhages may extend into the muscular tissue. There are 
hemorrhages into the mucous membrane of the hard palate and gums. 
Symptoms. — Mild cases sometimes escape notice. An ansemic 
infant may cry when bathed or may favor one extremity. It may 
hold one thigh rigid or cry when the limb is handled in the process 
of diapering. Mothers at first suspect traumatism. The infant 
develops slight ecchymoses on the tibiae, and is then brought to the 
physician. If there are teeth, there may at this stage be no swelling 
of the gums or of the extremities. There is no fever ; there may 
not be any anaemia. In the severer cases the symptoms are more 
marked. The skin in the infant of from seven to nine months 
of age acquires a pallid or greenish tinge. The infant cries when 
touched. One or both of the lower extremities lies as if paralyzed. 
If an attempt is made to move them, the infant appears to feel pain. 
The limb is swollen in the course of the shaft or in the vicinity of the 
knee or ankle, the swelling extending up the shaft (Plate XXVIL). 
Tlie ribs are apparently tender. There may be one or two subcu- 
taneous ecchymoses on the surface of the body. If there are teeth, 
the gums, especially those of the upper jaw, are swollen into cushion- 
like formations. These bleed easily and may partly conceal the teeth. 
If there are no teeth, the gums may appear normal, or the free bor- 
der, especially of those of the upper jaw, may have a bluish, swollen 
appearance, which may be very slight or quite marked. The infants 
may have a capricious appetite, may take little of the bottle or may 
nurse ravenously. 

The very severe cases have, as a rule, been allowed to run on for 
months in the belief that the infants were suffering either from rheu- 
matism or dropsy. For some time before coming under treatment, 
the infant has cried when diapered or when the shoes or stockings 
were put on ; later it becomes pale and loses ground. The appetite 
is poor. The thighs and the ankles begin to swell. The child does 
not move the extremities, which are swollen to twice or three times 
the original circumference. Ecchymoses appear on the surface of 
the swellings of the legs and thighs. Parts of the skin acquire a 
bluish-green, bruised appearance. Deformity occurs in the thigh, 
especially at the junction of the diaphysis with the head of the bones. 



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INFANTILE SCORBUTUS OR SCURVY. 



725 



This is due to infraoture or loosening of the epiphyses at the epiphy- 
seal line. The costochondral junction of the ribs is much swollen. 
There is a distinct series of very large swellings in this locality 
which are due to hemorrhage into the line of juncture of the rib and 
cartilage. Ecchymoses and sugillation appear about the orbit. The 
face and eyes have an oedematous, hydrsemic appearance. The 
gums may not be at all affected, but if the infant has teeth there 
may be sponginess. 

When the physician examines the infant, he finds that the pain 
produced by the procedure causes it to shriek with agony. The 
ribs are painful to the touch. The swellings on the thigh are uni- 
formly fusiform, and, as a rule, hard and not fluctuating. The ab- 
domen is tense and tympanitic. The infant has had some bleeding 
from the nose, but not necessarily from the bowel. In other cases 
there are not only hemorrhages from the bowels, but also from the 
kidney, in the form of hsematuria. There may be albumin and casts 
in the urine, or these may be absent. 

Of especial interest are those cases in which hsematuria is the 
chief and only objective symptom of the disease. Such cases as I have 
seen the infants may be in excellent physical condition, of good 
weight and color, and still for a period of weeks have voided urine 









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Temperature-curve of a case of scorbutus in an infant seven months of age. Resorp- 
tion fever. The chart shows the very high number of respirations as compared to the pulse. 
Cause of high respirations probably pain and extreme ansemia. The curve taken from 
the start of treatment. 



which contains blood, but no casts. Careful examination of such cases 
will reveal a tenderness of the tibise, or a just perceivable swelling 
of the gums or a very narrow blue line along the gums. I have 
recently seen a number of cases of scorbutus in which the main 
symptom was the appearance of blood in the stools, simulating a 
dysentery. In another case, that of a child tw^enty-two months of age, 
the first symptom of scorbutus was a sharp hemorrhage from the bowel. 
This hemorrhage was repeated, but was not as profuse as the initial 



726 DISEASES OF THE BLOOD. 

one. A careful examination in this case revealed a slight tender- 
ness of the tibiae and a tendency to ecchymoses following the least 
traumatism. 

The pulse is, as a rule, not increased. In one case without com- 
plicating pneumonia, in which I found the respirations enormously 
increased, I reached the conclusion that the increase was due to the 
pain and extreme anaemia. 

In severe cases there may be slight temperature (Fig. 159), 
which may be due to resorptive fever caused by the immense 
extravasations of blood. 

The hemorrhages in the skin may be localized in the form of 
minute petechise or there may be ecchymotic blotches of considerable 
size. The latter may appear over the swellings along the bones. 

The fractures or infractions were present in only 9 cases of the 
set collected by the American Pediatric Society. The gums Avere 
generally affected in infants with teeth, and were swollen and spongy 
in 24 cases in which there were no teeth. They may be normal in 
severe cases if there are no teeth, and swollen in mild ones. The 
symptoms in older children resemble those of adults. In one case 
in a child over two years of age the surgeons of a dental clinic had 
been consulted for an uncontrollable bleeding of the gums. The 
child had ceased to walk on account of pains in the lower extremities, 
which had been interpreted as rheumatic. In older children the gums 
are affected, and the hemorrhages take the form of petechise and 
blotches, appearing in crops over the surface of the body as in the 
adult. They have joint-pains and malaise. 

Prognosis. — The disease in infants and children gives a very 
good prognosis if recognized and treated in time. Most cases recover. 
The fatal cases are those in institutions or elsewhere in which the 
diagnosis has not been made or in which death has been caused by 
some intercurrent afPection, such as cerebral hemorrhage, diarrhoea, 
or pneumonia. In 379 cases collected by the American Pediatric 
Society the mortality was 8 per cent. 

Duration. — There is no fixed duration. Much depends on an 
early diagnosis. Even if the disease has existed months before 
a diagnosis is made, the patient may still recover. The great danger 
is that a hemorrhage may occur in the cerebrum or that the infant 
may contract an intercurrent affection through exhaustion. If allowed 
to continue without treatment, the disease may cause exhausting intes- 
tinal hemorrhages or hemorrhage of great extent elsewhere, with 
consequent anaemia and death. 

The diagnosis of infantile scurvy presents no difficulties. The 
pains in the extremities, the paralytic phenomena, the swelling of the 
gums, the swelling in the vicinity of the joints of the limbs or along 
the shafts of the bones, the swellings on the ribs, and the ecchymoses 
in the skin and about the eye, are all characteristic. The pareses of 



INFANTILE SCROBUTUS OR SCURVY. 727 

the upper extremity are frequently mistaken for those due to syphilis. 
The history, and the absence of syphilitic eruptions will aid in diag- 
nosis. In the presence of a haematuria in an artificially-fed infant, 
where other causal elements fail we should always think of the pos- 
sibility of scurvy. In cases of prolonged enteric catarrh, in which 
the infants are emaciated and pass pure blood with the movements, 
scurvy should be thought of. I have seen a case of scurvy with 
hemorrhages from the bowel mistaken for intussusception, and 
operated with this mistaken diagnosis in view. 

The treatment of infantile scurvy is simple and satisfactory. 
The infant is given fresh, pure milk properly modified. The milk 
should be given raw, and in summer should be kept well packed in 
ice. In addition, orange-juice and lemonade are given in the 
course of the day. An infant seven months old should have 2 
ounces of lemonade and J ounce of orange-juice in twenty-four 
hours, given every two hours after each nursing. Some authors 
advise the giving of raw beef-juice, but it is not necessary. After 
two weeks the quantity of fruit juice should be reduced, but a small 
quantity of orange-juice should be given daily for some time. Medi- 
cines are not indicated except for the anaemia, which is best treated 
by doses of half a drop of Fowler's solution given three times daily, 
or by some easily assimilable peptonate of iron. 

Keferences of Authorities for Collateral Keading. 

''American Pediatric Society Collective Investigation of Scurvy," Trans. 

Amer. Ped. Soc, vol. x. 

Barlow : ' ' Cases Described as Acute Rickets," Med. and Chir. Trans., Lond., 
1883. 

Burkel: Chronische Milzschwellung, Dissert, Miinchen, 1898. 

Carr, W. L. : "Case of Scorbutus," New York Med. Rec, 1892. 

Carstanjen, 31. : " Weiss. -blut Korperclien beira Menschen," Jahrb. f. Kinder., 
1900. 

Cheadle: "Cases of Scurvy and Rickets," Lancet, 1878. 

EhrUch and Lazarus: "Die Ansemie," Nothnagel's Spec. Path, und Tlierap., 
Bd. viii. 

Ehrlich, P.: Histologic des Blutes, Berlin. 1891. 

Escherich, T. : "Status Lymphaticus," Berlin, klin. Wocli., 1896. 

Oee: "Osteal and Periosteal Cachexia," St. Bart. Hosp. Rep., 1881-1889. 

Geissler and Japlia: " Beitr. zur Ansemie," etc., Jahrb. f. Kinderheilk., 1901. 

Gundobin : " Morph. u. Path, des Blutes," Jahrb. f. Kind., 1893. 

Hayem, G. : Du Sang, Paris, 1889. 

Hoch and Schlessinger : " Hsematolog. Studien," Beitrg. zur Kinder., 1892, 

Henoch, E. : " Uelser eine Eigenthiim Form von Purpura," Verhandl. Berlin. 
Med. Gesell., 1874. 

Jacobi, A.: "Anatomy and Pathology of Thymus," Trans. Assoc. Amer. Phys., 
1888. 

• Archives of Pediatrics, 1892. 

Jaksch, v.: " Ueber Leuksemie u. Leukocytose in Kindeaalter," Wien. med. 
Wochen., 1890. 

Japha, A.: " Leucocvtose," etc., Jahrb. f. Kinder., 1901. 

Koch, Wm. : " Die BInt-Erkrankheit," Deutsche Chir., Lief 12. 

Limbeck, R. R. : Grundriss klin. Path, des Blutes, 1892. 



728 DISEASES OF THE SUPRARENAL BODIES. 

Monti and Berggriln: " Die chronische Anaeinie," etc., Wien, 1892, 
Morse, J. L.: '' Infantile Scorbutus," Boston Med. and Surg. Jonr., 1901. 

"Chronic Enlargement of tlie Spleen in Infancy," Annals Gynsecol. and 

Ped., 1900. 

Northrup and Crandall: "Infantile Scurvy," New York Med. Jour., 1894. 
Northrup: "Scorbutus," New York Med. Kec , 1889 ; Archiv. of Fed., 1892. 
Os/er, Wm. : "Sporadic Cretinism in America," Amer. Jour. Med., 1895. 

''Cretinism in America," Trans. Cong. Amer. Pliys., 1897. 

Botch and Lladd: ''Pernicious An?emia," Trans. Amer. Ped. Soc, 1901. 
Sckiff, E.: "Hjematolog. Studien der Neugeborenen," Jabrb. f Kind., 1901. 
Scbodel and Nauwerck, Moller, Barlow, Krankheit., Jena, 1900. 
Schmorl: Verhandl. Versammlung Deutscb, Naturforsch., 1899. 

" Ueber Storungen des Knocbenwacbstums bei Barlow'scben Krank- 
heit." 

Stengel and White: "The Blood in Infancy ^nd Childhood," Trans. Amer. Ped. 
Soc, vol. xii. 

Thomson, J. : "Sporadic Cretinism," British Medical Journal, 1898. 

"Achondroplasia," Edinburgh Medical Journal, 1893. 

"Thyroid Feeding in Cretinism," Edinburgh Medical Journal, 1894. 

Triesethau, Wm. : Die Thymus, Dissert., Halle, 1893. 

Van Arsdale, W. W. : "Cervical Adenitis," Trans. New York. Acad, Med., vol. 
viii. 

Wentworth, A. II.: " Assocation of Ana?mia and Chronic Enlargement of the 
Spleen," Trans. Mass. Med. Soc, June 11, 1901. 



VI. DISEASE OF THE SUPRARENAL BODIES. 

Addison's Disease. 

[Morbus Addisonii.) 

This is an exceedingly rare affection before the tenth year of 
life. Of 48 cases collected by Dezirot, only 6 occurred before the 
tenth year. Most of the cases collected by this author (in diildreyi) 
occurred before the twelfth and fifteenth years. It may occur in the 
newborn. It is caused by tuberculous degeneration of the suprarenal 
capsule, although in one case there was carcinoma of this organ. 
Apart from asthenia and raelanodermie, gastro-intestinal disturbances 
and couvulsions dominate the development of the disease. Vomiting 
is very frequent. The conjunctiva and nails escape pigmentation. 
The duration is shorter and the disease more rapidly fatal in children 
than in adults. Sudden death is a frequent termination. Enlarge- 
ment of the mesenteric lymph-nodes and Peyer's patches and soli- 
tary follicles have been observed. The pigmentation of the buccal 
and other mucous membranes remain, as in the adult, pathognomonic 
of the disease. It must be differentiated from tuberculosis of the 
peritoneum with melanodermie and gastro-intestinal crises. Pigmen- 
tation, however, of the mucous membranes remains characteristic of 
Addison's disease. 

Treatment. — Inasmuch as the operative treatment in adults has 
in certain cases caused an amelioration of the symptoms, it might 
also be tried, if the diagnosis is certain, in children. 



SECTION X. 

DISEASES OF THE BONES. 

General Facts. — In examining the joints, it should be borne in 
mind that the bones entering into the formation of the joints may 
be affected. The diaphysis may be diseased without accompanying 
involvement of the joint. 

Tuberculosis. — In all bone lesions tuberculosis should be excluded. 
In infants and children, the question as to whether the existing 
condition is tuberculosis of the bone or syphilis is constantly arising. 

Syphilis affects by predilection the long bones in the diaphysis, 
while tubercle affects the short bones, especially in the vicinity of the 
joints. In this region, also, tubercle attacks the epiphyses of the 
bone and may thus involve the joints secondarily. 

Pain in syphilitic bone lesions is very marked, acute, and with 
nocturnal exacerbations ; while the pain of tubercular bone lesions 
is obscure and indefinite, although persistent. 

The swelling in syphilis is in the form of a periostitis or an ostitis 
involving only the bone ; in tuberculosis, the surrounding tissues are 
affected as well as the bone, and abscess and fungous granulation 
result. 

Syphilis rarely suppurates ; the contrary is true of tuberculosis. 

Syphilis of the bones does not as a rule lead to cachexia ; tuber- 
culosis of the bone eventually causes cachexia and emaciation. 

There are cases in which doubt will arise as to the true nature of 
the bone affection. This is especially the case when the small bones 
of the hand are affected. 

Sudden painful swelling of the long bones occurring in corre- 
sponding bones on both sides should awaken a suspicion of syphilis, 
even in the absence of other signs of syphilitic disease. A long 
bone which has been affected by syphilis will be irregularly thick- 
ened, owing to the repeated attacks of periostitis. This thickening 
is likely to be confounded with that caused by rachitis. 

In rachitis, the bone is less painful than in syphilis and the 
thickening is invariably uniform and smooth. In scurvy there 
may be a thickening of the long bones due to hemorrhage in the 
periosteum. In these cases the history and also the presence of other 
signs of scorbutus, such as hemorrhages in the skin or bleeding of 
the gums, will aid diagnosis, 

729 



730 DISEASES OF THE BONES. 

Craniotabes. — In locating patches of so-called craniotabes, the 
surface of the occipital and other bones of the skull is examined 
for deficiency of bone formation. Th(; occipital bone will in rachitis 
present membranous spots more frequently than is gcnierally sup- 
posed. The most common tumors found on the scalp are those 
due to traumatism at birtli, such as cx^phalohsematoma, tumor of 
the scalp with de|)ressed bone, and tumor due to syphilis. The 
cephaloha3matoma is found after birth and need not l)e described 
here. If an infant falls on on(i side of the head from a height, a 
depression of the skull may at once take place. This occurs if the 
bones are soft and not yet completely ossified. The depression is 
filled with an eifusion of blood and serum. A soft tumor results 
which may not ])roject above the surface at all or only slightly so. 
Around the bonk^r of the tumor the rim of bone bord(UMng the de- 
pression can be felt. In this resj)ect the condition diifers from the 
cephalic hsematoma found after birth. In the latter, the whole 
tumor is raised from the surface, and on j)hysical examination 
there are no evidcaices of depression. 

Syphilis (Fig. 83) may cause on the surface of th(? frontal and 
parietal bones tumors varying from the size of a hazelnut to that 
of a walnut. They may at first be hard and subsequently soften. 
They resemble abscesses, and should be differentiated from them. 
Tuberculosis of the bones may also cause such tumors. Tuberculosis 
of the skull bones in infancy is of rarer occurrence than syphilis of 
the skull, the cases of disease of the ear being excepted. In a concrete 
case, syphilis should be assumed until it can l)e excluded. Abscess 
may be diagnosed if there are abscesses elsewhere in the body. This 
is the (;ase in folliculitis abscedens of Escherich. Mistakes rarely 
occur in these cases, since all the signs of abscess are |)resent. 

Acute Infectious Osteomyelitis. 

Osteomyelitis is an acute infectious inflammation of the struct- 
ure of the bones. It is common in infancy and childhood. Of 
50 cases below the thirteenth year collected by Blumenfeld, 50 i)er 
cent, werci und(T five years of age. Tlie sc^xes were e(|ually affected. 

Etiology. — In the majority of cases the essential cause is the 
Stai)hylococcus pyogenics aureus. The disease may, however, be 
caused by any })yogenic micro-organism, such as the Streptococcus 
pyogenes, tin; ])neumococcus, the Bacillus typhosus, the Recurrens 
si)irillum, I^acterium coli, and the gonococ(uis. Of 90 cases collected 
and reported by Lannelongue, only 10 were due to the strepto- 
coccus. Lannelongue and Ac^hard were the first to show that osteo- 
myelitis may be caused by streptococci, in 1890. Van Arsdale and 
I, in 1891, pu})lished 4 cases of osteomyelitis caused })y strepto- 
cocci. These occurred in newborn infants or followed scarlet 



ACUTE INFECTIOUS OSTEOMYELITIS. 731 

fever and pneumonia. The streptococcus osteomyelitis is of especial 
interest to the physician, as it occurs in infants and children under 
two years of age. It frequently follows infection of the umbilicus 
in the newborn infant, the exanthemata (scarlet fever and measles), 
and pneumonia. It differs from the staphylococcus variety in that 
the inflammation of the bone is less likely to involve the medullary 
canal, but affects the epiphysis. There is also involvement of the 
joints, with suppuration. The bacteria gain access to the circula- 
tion (Garre), and to the bones through some wound, such as the 
umbilicus ; through the mucous membranes, as in ulcerations of the 
mouth ; through some lesions of the skin, such as an eczema or fur- 
uncle, or through the gut. Of the 47 cases cited above, 1 7 were due 
to trauma, and 5 followed infectious diseases. 

Pfisterer has recently published 7 cases of arthritis caused by the 
pneumococcus. In most of these cases the disease was monarticular ; 
though in one case several joints were involved. The arthritis of 
this variety for the most part involves the larger joints. The symp- 
toms are similar to the streptococcus form, and yield kindly to treat- 
ment. Some of the cases may complicate a pneumonia, or they may 
also occur independently of this disease. If complicating a pneu- 
monia, the affection may appear from the first to the ninth week of 
convalesence. 

Morbid Anatomy. — The seat of inflammation is the periosteum 
and the medullary substance of the bone chiefly. The inflammation 
of the marrow and spongy part of the bone involving the cortical 
bone layer is often spoken of as osteitis, that of the periosteum as 
periostitis. There is a primary form and one secondary to infections 
elsewhere in the body. It is a disease of young people and involves 
mostly the long bones. The periosteum is swollen, hypersemic, the 
seat of hemorrhages and finally of purulent infiltration. The bone 
marrow and neighboring bone tissue is hypersemic, the seat of hem- 
orrhages, and after a time purulent infiltration. The whole marrow 
canal may be converted into a pus cavity, and pus may form under- 
neath the periosteum. The bone tissue becomes infiltrated with pus, 
breaks down and forms sequestra. Abscesses may form in the bone. 
In the subsequent history of the separation of the diseased from the 
healthy bone the processes are those seen in all bone inflammations. 

Symptoms. — In older children, the symptoms differ little from 
those of the adult subject. The femur and tibia are most commonly 
involved ; next the humerus, superior maxilla, inferior maxilla, ileum, 
and radius, in the order named. In some cases the onset is sudden 
and the fatal issue takes place in a few days. In others, the inva- 
sion is gradual. In older children there are the regular symptoms 
of chill, fever, and vomiting, followed by local symptoms. 

In young infants the signs of osteomyelitis are obscure. In the 
puerperal cases in newborn infants, the umbilicus may be inflamed 



732 DISEASES OF THE BONES. 

for some days, after which the infant begins to cry when handled in the 
bath. One extremity is not moved and a joint may be swollen (Plate 
v.). Swelling of the joint may escape notice until the child is examined 
by the physician. After scarlet fever, the swelling of the joints is 
quite apparent, and also after pneumonia. In the newborn infant 
several joints may be swollen. In one of my cases in an infant 
ten months old, the elbow-joint and wrist-joint were involved, 
the whole radius being the seat of osteomyelitis. Similar cases 
have been published in this country by Gibney. The frequency 
of joint-involvement is a feature of osteomyelitis in children. Of 
50 cases of osteomyelitis published by Blumenfeld, the joints were 
involved in 30. I have seen the multiple joint-suppurations most 
frequently in newborn infants. In all cases, there are evident swell- 
ing of the tissues about the joints and fluctuation in the joint-cavity. 
The joint contains pus. 

The diagnosis is not difficult. If an infant cries when it is 
handled, every joint should be carefully examined. Osteomyelitis 
may be confounded with scorbutus. In the latter affection, the 
joints are painful and swollen, but do not contain fluid. In 
scorbutus there are ecchymoses, swelling and sponginess of the 
gums, and hemorrhagic lesions underneath the skin, all of which 
will aid in diagnosis. A history of umbilical inflammation or of 
scarlet fever is of great value. There are in congenital syphilis in 
young infants forms of inflammation about the joints which at first 
simulate osteomyelitis. In such cases the infant should be exam- 
ined for other evidences of congenital syphilis, such as fissures and 
rhagades about the mouth and anus, mucous patches, and coppery 
discolorations of the skin. Tuberculous inflammation in the long 
bones or in the heads of the bones may present some difficulties 
of diagnosis. A study of the case and the absence of a history of 
acute trouble will solve the difficulty. 

The prognosis of acute osteomyelitis in newly born infants is 
bad. The majority of cases are fatal owing to the formation of 
multiple foci of suppuration. The prognosis is also bad in infants 
under one year of age. The mortality of all cases under the fifth 
year is 56 per cent. In older children it is 20 per cent. 

The treatment of acute infectious osteomyelitis is surgical. 



SECTION XI. 

DISEASES OF THE EAR. 

Otitis in Infancy and Childhood. 

Frequency. — Otitis media, catarrhal or purulent, is a very 
common disease of infancy and childhood. It is, as a rule, a sec- 
ondary affection, but may in rare cases occur as a primary disease. 
Parrot first called attention to the frequency of otitis as a complica- 
tion of bronchopneumonia. Netter made the first bacteriological 
examinations of the discharges from the ear. The subjects were 20 
children whose ages ranged from nine days to two years. Kossel, 
Kasch, and Ponfick have investigated the frequency and nature of 
this affe(;tion in children. The results of their work show striking 
uniformity. Fully 85 per cent, of infants and children, examined 
post mortem, were found to have diseased ears. Most of the infants, 
especially in the material examined by Ponfick, had died of gastro- 
enteritis, acute or chronic. Some had suifered from gas tro -enteritis, 
pneumonia, or congenital syphilis. 

The etiology of acute catarrhal, acute suppurative otitis media 
and of acute suppurative mastoiditis. is much the same. The naso- 
pharynx and the Eustachian tube are normally the habitat of various 
forms of bacteria. This is especially the case in infants and chil- 
dren who have enlarged tonsils and adenoid growths. A reduction 
of the vitality of the individual or any acute disease favors inva- 
sion of the ear by bacilli entering through the Eustachian tube. 
Thus the exanthemata, especially scarlet fever and measles, furnish 
a large quota of cases. Diphtheria, typhoid fever, typhus fever, 
varicella, influenza, gastro-enteritis, tonsillitis, and simple angina, 
also cause a large number of cases of otitis. Pertussis, cerebrospinal 
meningitis, and pneumonia are complicated by this disease. Sea- 
bathing, exposure to cold, and nasal douching favor its onset. 

Bacteriology. — The bacteria found by different observers in the 
otitic discharges and in the cavities of the ear include the Staphy- 
lococcus pyogenes aureus, citreus, and albus, the Streptococcus pyo- 
genes, the pneumococcus of Frankel, the influenza bacillus and 
pseudo-influenza bacillus, the Bacillus foetidus, and the Bacillus pyo- 
cyaneus (Netter, Kossel, Ponfick). The streptococci and influenza 
bacilli cause an especially severe inflammation, the pneumococcus 
a milder form. The diphtheria bacillus also causes otitis. 

Morbid Anatomy. — In both forms of otitis and also in mas- 
toid disease the tympanic membrane is injected and the vessels at 

733 



734 DISEASES OF THE EAR. 

its border are increased in size. The vessels of the hammer are 
injected. The epidermis of the tympanic membrane may be intact. 
The tympanic cavity may be filled with cellular elements. There 
may be a serous, mucous, purulent, or mucopurulent exudate. The 
mucous membrane of the tympanic cavity may be intact but injected, 
or may show gross defects. If the bony structures are involved, there 
will be necrosis of bone, especially of the tegmen tympani. There may 
be perforation of this structure or of the point of the mastoid process. 
The dura mater or sinuses of the dura may, in progressive mastoid, 
be inflamed. There may be cerebral abscess. If the pus does not 
escape by way of the Eustachian tube, it may perforate the tym- 
panum. The exudate which fills the tympanic cavity contains epi- 
thelial cells, leucocytes, and blood-cells. 

Otitis Media Catarrhalis. — Acute catarrhal otitis is, in a vast 
number of cases, simply a forerunner of otitis media purulenta or of 
an acute suppurative otitis. It will be convenient for the practitioner 
to consider these affections together. 

They are more common among infants and children than among 
adults, and may occur at the earliest period of infancy. They occur 
most frequently in the spring and summer. 

The causation has been considered under the etiology, and is 
the same in both affections. 

Symptomatology. — In young infants and in children under two 
years of age, the symptoms are frequently masked by those of the 
primary disease. In many cases, the otitis gives no special warn- 
ing of its presence. Perforation of the drum and a purulent dis- 
charge are the first intimation of the condition. This is especially 
the case in otitis in young nurslings who have suffered from acute 
tonsillitis or pneumonia, but these are not the cases which the practi- 
tioner is called upon to diagnose. In another set of cases, especially 
in those in which otitis is coincident Avith gastro-intestinal dis- 
orders of a chronic type, tending to atrophy, Heermann and Ponfick 
have shown that during life the otitis gives no objective symptoms 
although on otoscopic examination the tympanic cavity is found to be 
filled with pus. In cases which follow the milder types of influenza 
or angina, there may be a most puzzling set of symptoms v/hich can 
only be referred to the ear. In these cases the physician finds, two 
or three days after the onset of tonsillitis or influenza, that the 
temperature does not drop to the normal ; it may mount to 104° F. 
(40° C.) toward evening, and in the morning may drop to or within 
a degree of the normal. While the temperature is low the infant 
takes its food and plays. When it rises the infant becomes fretful, 
or stupid, or sleeps most of the time. There is no indication of 
pain. In some cases the infants perspire freely at the falling of the 
temperature. These simulate in many respects cases of malaria or 
of meningitis of the tuberculous type, except that the tempera- 
ture rises higher than in the latter disease (Fig. 160). Local facial 



OTITIS IN INFANCY AND CHILDHOOD. 



735 



pareses may complete the resemblance to meningitis. The intermittent 
or recurrent curve of temperature may continue for a week or ten days. 
Only the careful exclusion of disease of other organs, and especially 
of the lungs and of the heart, will lead the physician to suspect 
disease of the ear. In nursing infants the bowels will be abnormal 
and the movements greenish, containing white curds. The tempera- 
ture is, however, much higher than in any diarrhoea, and is more 

Fig. 160. 



DISEASE 1 



, 107'- 

106' 

105 

. 104' 

^ 103' 

m 102' 

H 101' 

100' 



^^ 



^-%A 



U 



'H 



Pz 



Otitis media purulenta in a child eighteen months of age. Symptoms and curve simulating 
closely a meningitis of the basal type. 



persistent and regular in its daily fluctuations. In cases of broncho- 
pneumonia complicated with otitis, previous to the spontaneous per- 
foration of the drum the temperature will have shown more decided 
fluctuations than would occur at a late stage of the primary disease. 
However, in pneumonia there are few or no objective signs of the 
affection. Older children may have certain definite symptoms such 
as dull headache and pain in the ear, which, if sharp and sting- 
ing, will cause them to start in sleep, or to awake and cry out or 
put the hand to the ear. This last sign, so often mentioned in the 
text-books, I have seldom seen. There may be delirium and the 
fever may be quite high. Children, who can talk, complain of pain 
at night. There may be rushing, singing, or buzzing noises in the 
ear. Very characteristic is the starting of infants during sleep. 
Older children are out of sorts, and angry on awakening. 

Course. — Spontaneous perforation in a number of cases occurs 
in a few hours or a few days after the onset of the disease. As a 
rule, however, pain continues with fever until artificial paracentesis 
of the drum is practised. After spontaneous rupture of the tympa- 
num, or paracentesis, the discharge may continue, being in some 
cases serous or serosanguinolent, and later becoming purulent. The 
purulent discharge may be profuse and the disease may advance into 
the mastoid or labyrinth. This frequently occurs in cases of the ex- 
anthemata or in pneumonia or influenza. In severe cases, the 
discharge may continue and become chronic, resulting in destruction 
of the structures of the ear. Complications may intervene, such as 
facial erysipelas, meningitis, cerebral abscess, thrombosis of the 
cerebral sinuses, and finally in suppurative cases pyaemia may inter- 
vene. On the other hand, after spontaneous rupture or paracentesis 



736 DISEASES OF THE EAR. 

of one or both drums, the serous or purulent discharge may gradually 
cease and the ears be restored without any defect of hearing. In 
many cases incision of the dram in the very early stages of the dis- 
ease is not followed by the discharge of pus ; the symptoms cease, 
and the patient recovers. In other cases there is no rupture of the 
tympanum, although the tympanic cavity is filled with exudate, 
which discharges through the Eustachian tube. The pus may be 
swallowed and cause diarrhoea or pneumonia. In the cases of 
marasmus with otitis described by Heerman, the pus is believed 
to have found its way from the middle ear through the tube to the 
nasopharynx. 

The diagnosis is first made from the rational symptoms. In my 
experience, the temperature-curve is a very useful guide in infants 
who give no evidence of pain. Otoscopic examination is the only 
positive means of making a diagnosis. There is congestion of the 
tympanum above Shrapnell's membrane and the long handle of the 
malleus. In the catarrhal cases the tympanum is red and angry 
or has a grayish lustre. The handle appears as a red or yellowish- 
white point. In some cases there are vesicles and interlamellar 
abscess. The exudate may cause bulging of ShrapnelPs mem- 
brane or of the posterior-superior quadrant. Congestion remains 
long after resolution. In the suppurative cases the epithelium 
of the tympanic membrane may peel off. The tympanum is dull 
and lustreless. The auditory canal may be swollen. Perforation 
occurs, chiefly in the posterior-inferior quadrant. There may 
be pulsation of the membrane as well as bulging. The lymph- 
nodes beneath the ear may enlarge and that region may be very 
sensitive. 

The prognosis in ordinary cases is good. In cases following the 
exanthemata it is grave, on account of the possibility of complica- 
tions and of ultimate loss of hearing. 

THE MASTOID REGION. 

General Facts. — The mastoid region is important on account 
of the frequency of mastoid disease in infancy and childhood. In 
early life there is pneumatic tissue, but no mastoid cells are found. 
The mastoid process contains one large cell (Symington). The exter- 
nal wall is less thick and compact than in the adult. The petro- 
squamous suture is patent. The petrosquamous sinus is persistent in 
some cases, passes through a foramen on the inside of the skull, and 
appears externally behind the glenoid fossa and tympanic ring. 
Thus infectious material may easily be conveyed internally. In 
infants and children pus finds its way externally more readily 
through the open fissura mastoideo-squamosa. 

Etiology. — Inflammation of the mastoid is rarely primary. The 
mastoid may at the outset be inflamed when there has been no ante- 



THE MASTOID REGION. 737 

cedent otitis. As a rule, however, inflammation of the mastoid is 
secondary to acute or chronic otitis. The causation is identical with 
that of acute or chronic otitis. 

Of 39 cases of mastoid disease under eight years of age, collected 
by Knapp, 7 occurred in the first year, and 9 in the second. The 
greatest frequency is therefore after the second year. It may occur 
as early as the second month. I have had a case in an infant three 
months of age. The anatomical conditions favor the occurrence of 
mastoid disease in infancy and childhood. The Eustachian tube is 
short and of large calibre ; infectious material from the nasopharynx 
can easily gain access to the ear. 

Symptoms. — Clinically, mastoid disease in infancy and childhood 
manifests itself by rational symptoms and physical signs. There 
may be extensive mastoid disease without any external physical 
signs. In one of my cases of otitis, which was observed from the 
outset, extensive mastoid disease in a child of three years of age did 
not give any external signs. The clinical symptoms are character- 
istic. The drum may have been perforated after otitis, or paracen- 
tesis may have been performed. After perforation, the temperature 
present during the preceding otitis drops to the normal. The patient 
is able to be up and about. The ear discharges freely. After two 
or three weeks there is a sudden or gradual rise of temperature, 
which may be slight or may reach 103° or 105° F. (39.4° to 40.5° 
C). There is restlessness at night. On inspection, the ear may not 
show anything abnormal. The temperature, however, continues to 
be remittent for several days. On otoscopic examination, there is 
found to be swelling of the roof of the auditory canal or of the floor 
of the attic. In other cases, after a very early and timely paracentesis 
of the drum, the patient does not do well. The child is restless at 
night, at intervals irritable and then playful, and starts from sleep 
(Fig. 161). The temperature fluctuates daily from 100.8° to 102° 
F. (38.8° C). On some days it may be normal or subnormal. The 
ear discharges for days, but a slight temperature continues. If the 
patient is an infant or a young child, it may be very difficult to ascer- 
tain whether pain is present on pressure backward over the region 
of the antrum behind the ear. There is in early cases no swelling 
or redness behind and above the auricle. As was stated above, 
there may be extensive and advanced mastoid disease without exter- 
nal redness or swelling. In such cases the lymph-nodes behind the 
ear and at the angle of the jaw may be swollen and painful. Young 
children and infants do not complain of pain. It is only in older 
children that it can be noted. 

Mastoid disease which follows the exanthemata, especially scarlet 
fever or measles, or occurs late in typhoid, shows certain charac- 
teristic clinical features. During the fifth or sixth week of scarlet 
fever the ears may discharge profusely. There is a daily rise of tem- 

47 



738 



BISEASES OF THE EAR. 



perature in the afterDoon, which is slight in some cases. The 
patients play in the early portion of the day, but in the afternoon 
appear listless, and have a slight frontal headache. As days pass, 
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otitis media in a female child, three years of age. Observed from the onset. Early 
paracentesis, fall of temperature, then rise again. Subsequent mastoid involvement neces- 
sitating operation. 

In many cases of scarlet fever, as may be seen by referring to 
Figs. 30 and 31, otitis is a complication. The temperature does not 
fall to the normal, as it should, after the fading of the eruption. 
There is slight aural pain at night, which is sometimes sufficiently 
severe to deprive the patient of sleep. In other cases the tem- 
perature drops to the normal and suddenly rises in the second 
week. In both these sets of cases there is an otitis which may 
develop into mastoid disease, or in which mastoid disease may have 
been present from the outset. 

Korner calls attention to the fact that in late typhoid fever, chills, 
with rises of temperature, may be, in the absence of other signs, indi- 
cative of serious mastoid disease. 

Physical Signs. — Pain is a physical sign of mastoid disease 
in children. In most cases it cannot be elicited by the most skilful 
manipulation. In others it is impossible to come to a definite con- 
clusion. In older children pain may be elicited by pressing the mas- 
toid bone in a backward direction, care being taken not to press on 
the auricle. The pressure should be firm and continuous. Pain in 
the tip of the mastoid is not of value unless there has been a per- 
foration and phlegmon at that point (Dench). 

Otoscopic Examination. — There is a shortening of the external 
canal in its posterior and upper aspect (Dench). The upper posterior 
wall sinks. There is bulging of the upper portion of the tympanum. 

Tumefaction posteriorly and above the ear occurs in infants only 
in neglected cases. According to Dench, in these cases the pus 
escapes from the antrum through the aditus ad antrum into the tym- 
panic vault. It then finds its way through the Rivinian fissure 
along the upper wall of the canal to the external surface of the mas- 



THE MASTOID REGION. 



739 



toid. In children cases in which this swelling appears are less 
serious than adult cases. The swelling also appears much earlier in 
infants and children. 

Fig. 162. 




Mastoid disease in a child eighteen months of age. Swelling behind the ear over the mastoid. 
The ear is displaced away from the scalp. 

Diagnosis. — The life of the patient often depends upon the early 
recognition of mastoid disease. The diagnosis in infancy and child- 
hood should not only be made early, but should be made chiefly from 
the clinical symptoms of temperature, which will in its fluctuations 
show a septic curve. The history of the case is of service. Pres- 
ence of pain is of no value in infants and young children. The 
daily otoscopic examination of the discharging ear will give positive 
evidence of mastoid disease. The signs detailed in the paragraph 
on symptoms are of great importance. A profuse discharge does not 
preclude mastoid disease. Facial paralysis is of no value. I have 
seen it in cases in which mastoid disease was on operation found to 
be absent. Tumefaction is seen only in late cases. Redness is 
sometimes apparent before the appearance of swelling behind the ear. 

Course. — If a case is neglected, pus from the mastoid may force 
its way through the tympanic roof and cause cerebral abscess or 
meningitis. It may destroy the plate (lamina vitrea) of the sigmoid 
sinus and cause thrombosis, may find its way through the tip of the 
mastoid along the border of the sternomastoid, and cause phlegmon, 
or may force itself through the sutura mastoideo-squamosa, causing 
swelling behind the auricle. 

Treatment. — Prophylaxis. ^Children can be taught to tolerate 
the therapeutic measures which, if catarrhal inflammation of the 



740 BTSEASES OF THE EAR. 

fauces is present, as in the exanthemata, will cleanse the parts. Thus 
in scarlet fever, an intelligent child will readily allow the throat to 
be sprayed with normal saline solution. Swabbing the throat or 
applying any drug locally is impracticable in children. 

If the pain is excessive a mild opiate, such as paregoric, is 
administered. In young infants the severity of pain cannot be 
estimated. In older children dry heat applied externally to the 
ear by means of a water cushion relieves the pain. Some authors 
advise the application of leeches behind the ear, or the instillation 
of water at 110° F. (43.3° C.) into the canal with a dropper. 
Inflation of the ear in the early stages of otitis media has been 
advocated and condemned. Suction by means of a catheter intro- 
duced into the Eustachian tube is also practised. If the pain and 
fever are not relieved by these measures, incision of the drum is re- 
sorted to. Whether the otitis is catarrhal or purulent, paracentesis 
is best performed early, since damage to the ear may thus be avoided. 
The method of performing paracentesis of the drum is best learnt 
from special text-books on the subject. Duel advises enlargement 
of the opening in cases in which spontaneous rupture of the drum 
has taken place. Drainage by the introduction of sterilized absorb- 
ent gauze into the canal is superior to syringing. If this is not pos- 
sible, syringing with 1 : 5000 bichloride is useful. 

The indications for the performance of mastoid operation are 
protracted otitis with profuse otorrhoea, there being no tendency to 
resolution, acute otitis in which there is a tendency to resorption 
and in which paracentesis has not established drainage, also muco- 
purulent otitis maintained by mastoid involvement, otitis with 
symptoms pointing to meningeal complications, and finally otitis with 
complicating stenosis of the external canal, preventing drainage. 

Eeferences of Authorities for Collateral Eeading. 

Babes, A. : Bacteriol. Untersuch. iiber septische Processeim Kindesalter, Leipzig, 
1889. 

Blumenfeld, F. : Acute Osteomyelitis im Kindesalter, Dissert., Marburg, 1900. 

Cohn, F. : " Indications for Perforating the Mastoid," N. Y. Med. Jour., 1896. 

Courmount et Jahoulay : " Sur les niici-ob de Tosteomyelite," Comp. rend hebdom. 
des Sciences de la Soc. Biol., 1890, No. 18. 

Dench: "Mastoiditis," Journal American Medical Association, 1901. 

" Mastoid Complications of the Exanthemata," Pediatrics, 1899. 

Duel, A.B.: "Acute Otitis Media and Mastoiditis in Scarlet Fever," Med. 
Review of Reviews, Michigan, 1901. 

Gaessler, B. : Mittelohres bei Scarlatina, Thesis, Wiesbaden, 1900. 

Hermann, G. : Otitis Media in friiheren Kindesalter, Halle, 1898. 

Korner, Otto : Die Otitischen Erkrankungen, 1896. 

Lannelongue et A chard : "Des Osteomyelite a Streptococque, La semaine M^d., 
1890 ; Academy of Sciences, 1890. 

Botch, T. M.: " Multiple Osteomyelitis in an Infant," Trans. Amer. Ped. Soc, 
vol. xi. 

Van Arsdale, W. W., and Koplik, H. : "Streptococcus Osteomyelitis," Trans. 
New York Academy of Medicine, vol. viii. 



SECTION XII. 

DISEASES OF THE KIDNEYS AND UROGENITAL TEACT. 

The weight of the kidneys is yi^ of the body weight in the in- 
fant and 2^Q- in the adult. 

It is not, as a rule, possible to palpate the normal kidney in the 
infant or child. I have, however, seen in young infants exceptional 
cases in which the kidneys were situated very low down and could 
be easily palpated through the abdomen. I have found floating kid- 
neys in infants and older children, but not so frequently as other 
observers. Comby in 1898 reported 18 cases, of ages ranging 
from one month to ten years of age. Steiner, Stewart, and Abt have 
also reported a number of cases. I believe that the displaced and fixed 
kidney is congenital. As the child grows and the parts are stretched, 
the attachments of the kidneys, congenitally low, become more 
relaxed. This would account for a number of cases. Jacobi be- 
lieves that floating kidney in children is a congenital anomaly. 

Sixteen of Comby^s cases occurred in girls. A displaced, fixed 
kidney in infants causes no symptoms. In cases of movable kidney 
or floating kidney the main symptom is pain, either epigastric or 
radiating from the iliac region. In a girl of eight years with float- 
ing kidney, there was no difficulty in palpating the enlarged movable 
kidney below the liver. There were attacks of acute colicky epigastric 
pain, which occurred independently of the ingestion of food. The 
child was nervous and hysterical. 

CYCLIC ALBUMINURIA. 

( Postural A lb uviinur ia. ) 

Cases of this form of albuminuria were first published by Vogel, 
Ultzmann, Gull, and Leube. The systematic description was first 
given by Pavy, by whom it has been carefully studied. 

Cyclic albuminuria occurs principally in children and adolescents ; 
40 per cent, of the cases occur in children from the first to the fif- 
teenth year, and 80 per cent, of the cases occur before the twentieth 
year. It is, therefore, distinctly a disease or condition observed in 
a period of metabolic activity and growth. 

The characteristic symptom is the appearance of albumin in the 
urine in the forenoon and afternoon, and its disappearance after a 
night's rest in the recumbent position. It is not present in the morn- 
ing directly after rising, but appears soon after the upright position has 

741 



742 DISEASES OF THE KIDNEYS. 

been assumed. The quantity of albumin is not excessive. It may 
disappear from the urine for days and weeks, and again reappear. 
The quantity of albumin does not progressively increase. The urine 
never contains formed elements of the kidney, such as casts. 

There is no doubt as to the existence of this form of albuminuria 
in children, but its significance is a matter of wide diversity of 
opinion. Heubner has lately published some cases, and has collected 
from the literature 22 cases in children from one to fifteen years of 
age. Some authors, among them Heubner, are inclined to give a 
good prognosis in these cases, and to regard them as physiological 
forms of albuminuria. Others, among them Henoch, Leube, and 
Senator, are inclined to regard them as due to insidious changes 
in the kidney following infectious disease. It should be remem- 
bered that after infiuenza, scarlet fever, or diphtheria, small quanti- 
ties of albumin are, at intervals, present in the urine for months and 
years. There may also be occasional hyaline or epithelial casts and 
a few blood-cells. These disappear either with or without treatment 
of diet and rest, but later reappear. I have seen this occur in 
children in good health. More careful data on the subject are needed. 
In a given case the urine should be carefully and frequently examined 
for kidney elements. It should be remembered that, in nephritis, 
the albumin in the urine frequently takes a cyclic course (Senator). 

So long as there is albumin in the urine, the prognosis must remain 
conditional on the prolonged observation of the patient, for a few 
of the published cases have in later years developed nephritis. It 
is said, also, that this form of albuminuria has been met in several 
members of the same family, and in families in which albuminuria 
and nephritis have existed. The term cyclic albuminuria should be 
limited to those cases in which there has never at any time previous 
to or during observation been any form-elements of the kidney in 
the urine. All the cases published, and those which I have observed, 
occurred in children with lymphatic constitutions. They showed 
a marked anaemia at times. There was an oedema of the face but 
not of the extremities. The children complained at various times of 
headaches or a heavy feeling in the occiput, were easily tired, awoke 
feeling tired. They were subject to dreams and were of a nervous 
temperament. In one of my supposed cases the child was free from 
the above symptoms, and was the picture of health. In this case 
there were periods early in the disease in which very scanty form- 
elements occurred in the urine with the albumin ; at others, none 
could be found. The case was at first diagnosed as cyclic albumi- 
nuria ; but my fears have been justified, inasmuch as lately the form- 
elements, such as casts and blood, have increased in the urine and 
have become permanent, thus showing the danger of diagnosing these 
cases on short periods of observation. Two cases which I have now 
under observation are classic, in that many repeated examinations (ex- 
tending over a year) of the urine have failed to reveal anything 



DYSimiA. 743 

pointing toward an affection of the kidney. The albumin is present 
some time after rising in the morning, and after exercise. It dis- 
appears on enforced rest. 

Treatment. — It has been proposed in cases of cyclic albuminuria 
to enforce at intervals periods of rest of one or two weeks at a time, 
and the limitation of exercise and sports. I have tried this method, at 
the same time dieting the patient, but have not found it as successful 
in improving the general condition of the patient as moderate out- 
door exercise in the open high country — freedom from mental worry, 
such as the suspension of studies ; good, simple food ; perhaps a 
tonic of the iron series. City and school life are not conducive to 
aiding the physician in treating these cases. A persistent anaemia 
sets in under these conditions, and is the symptom that baffles the 
physician in the treatment. Nothing will improve the patient so 
much as outdoor exposure in the open country. 

(EDEMA OR HYDRiEMIA WITHOUT KIDNEY LESION. 

Weak infants who have suffered from chronic gastro-enteric 
catarrh have swelling or an oedematous condition of the dorsum of 
the feet and ankles. There may be slight anasarca elsewhere. There 
is no real kidney lesion ; the condition is one of hydremia. The 
changed state of the tissues, including the vessels and blood, allows 
of a transudation of serum into the subcutaneous structures. On 
examination, the urine is found to be abundant and of low specific 
gravity, but without evidences of nephritic degeneration. In chil- 
dren of two years of age this condition of slight subcutaneous 
oedema occurs in simple anaemia of a severe type. In these cases 
the skin is yellowish, the ears have a waxy clearness, the eyes have 
an oedematous appearance, and the lips, hands, and feet are puffy. 
The condition is known as hydrsemia or hydrsemic anaemia. 

DYSURIA. 

Dysuria, or difficult and painful micturition, is a condition in which 
there is partial obstruction to the free flow of urine from the urethra. 
It is not uncommon in young infants and children, and may be due to 
a variety of causes. If lithiasis is the cause, there is not only pain in 
passing the urine, but there may, in the intervals, be acute attacks of 
pain, due to the passage of calculi along the ureter. Examination 
of the urethra in the male often results in finding a calculus of 
very small size in the anterior penile urethra. In lithiasis, there 
is sometimes very painful micturition without the formation of cal- 
culi of any size. The minute crystals of uric acid cause a smarting 
sensation as the urine passes over the urethra. In febrile states with 
concentrated urine, the acidity of the urine, and the excess of uric 
acid with free crystals, cause painful micturition. 



744 DISEASES OF THE KIDNEYS. 

Simple or gonorrhoeal inflammation of the urethra may cause 
difficult and painful micturition. Dysuria is painful at the onset of 
vulvovaginitis. Another condition of congenital origin, which was 
described by Bokai as cellular atresia of the labia, 'is a very 
common cause of dysuria. It is seen in very young female infants. 
From birth, the urine is passed in drops and with great straining 
and pain. In some cases it is passed without pain, but the condition 
of atresia attracts attention. On gently separating the labia majora a 
thin pinkish-white membrane is seen to occlude the introitus vaginae 
completely. At the urethral end of this membrane, a very minute 
opening is seen, through which the urine filters. These membranes 
can be divided by means of a dull director. It is then seen that the 
hymen and urethra are directly behind the membrane. The opera- 
tion of dividing the membrane is exceedingly simple, and causes 
little or no bleeding. Bokai has described a similar condition in 
boys, which is somewhat less common. It is a cellular adhesion 
of the prepuce and glans penis which not only causes false phi- 
mosis, but also difficult and painful urination. He found that in 
the newly born infant the prepuce was sometimes adherent to 
the tip of the glans penis, and that across the opening of the 
meatus there was a very thin membrane. In other cases, this 
membrane was ruptured, but the prepuce still remained adherent 
to the glans in front, while behind at the corona glandis there was 
retention of smegma and consequent painful inflanmiation. 

The treatment is division and separation of the cellular adhe- 
sions. Other abnormalities in infant boys, among them diverticula 
of the urethra, may cause dysuria. 

HiEMUTURIA. 

Hsematuria is the passage of blood and its elements into the 
urine, in which blood-cells and coloring-matter are found. The 
condition may occur in the following states : 

(a) Acute nephritis of all forms, especially those complicating 
the infectious diseases, such as scarlet fever, measles, typhoid fever, 
and malarial fever. 

(b) Calculi, renal or vesical. 

(c) Malignant growths of the kidney — sarcoma and carcinoma. 

(d) Growths of the bladder — polypus. 

(e) Traumatism in the region of the kidney. 
{/) The ingestion of drugs. 

(g) Scorbutus. 

The color of the urine varies from a slightly smoky amber to a 
deep brownish-red. There may be a deposit of blood-cells and clots 
in the urine. Pure blood with clots is seen in cases of malignant 
tumor of the kidney and calculi of the kidney or bladder. Smoky 
urine is seen in cases of nephritis and drug-poisoning. 



HEMOGLOBINURIA. 745 

HiEMOGLOBINURIA. 

Hsemoglobinuria is a condition in which the urine contains the 
coloring-matter of the blood, but, except in rare cases, no red blood- 
cells. The urine is reddish or brownish, and has a high specific 
gravity. It contains albumin. By spectral analysis, the spectrum 
of the blood coloring-matter is obtained. According to Hoppe- 
Seyler, methsemoglobin and not haemoglobin is often the coloring- 
matter present. There are few blood-cells and no detritus. Several 
theories have been advanced to explain the appearance of haemo- 
globin in the urine, that of Ponfick being generally accepted. 
According to that author, either the blood-cells are destroyed by 
some vicious agent or ferment (Ehrlich) and the haemoglobin is 
thus let loose into the circulation, or ih^ haemoglobin is dissolved 
out of the blood-cells and passes into the circulating plasma, leaving 
the cells behind as so-called " shadows." Whatever the real cause, 
the exciting influences are as follows : 

(a) Cold or exposure to wet. HofP and Demme have pub- 
lished cases of children with paroxysmal haemoglobinuria following 
such exposure. 

(6) Drugs, such as arsenic, phosphorus, potassium chlorate. 

(c) The infectious diseases, such as malaria and scarlet fever, 
erysipelas. 

(d) Haemoglobinuria has been observed in cases of burns. 

(e) Baginsky has observed haemoglobinuria in children with 
nematodes. 

One-half the cases published have a history of syphilis. Such is 
the case published by Hermann, occurring in a boy four years of 
age, with a history and physical marks of congenital syphilis. In 
this case the boy had at times attacks of haemoglobinuria. 

In the paroxysmal form, each attack is preceded by a chill and 
followed by dyspnoea, palpitations, cyanosis, and severe symptoms 
of collapse. The attack may last a few hours or a few days, the 
duration depending on the course of the primary affection. This form 
has been especially observed to occur in pernicious malarial fever. 

The prognosis is very good. Patients quickly recover from 
the attack proper, and there is no danger to life. The cases of 
syphilitic origin are not controlled by antispecific treatment, though 
the condition of the blood is improved. Chovostek succeeded in 
abating an attack by the administration of amyl nitrite. 

Morbid Anatomy. — Dieulafoy and Widal found in a fatal case 
the cortex of the kidney dark brown in color ; the cells of the glomer- 
uli were normal. The cells of the convoluted tubes and the tubes 
of Henley were infiltrated with pigment-granules, which were also 
present in the lumen of the tubes. 

The treatment consists not only in the management of the primary 
exciting conditions, but, if there is a history of syphilis, an antispe- 



746 DISEASES OF THE KIDNEYS. 

cific course of treatment is indicated. With this we may give tonics, 
such as iron, and exert a certain amount of prophylaxis by protect- 
ing the patient from cold, and also, if possible, securing to the patient 
wholesome food. 

RENAL CALCULI. 

{Uric Acid Infarction; Lithctmia.) 

So-called uric acid infarction is found in the kidneys of over 
one-half the infants who die in the first weeks after birth. These 
infarctions are seen in the medullary portion of the kidney as 
golden-yellow or brownish rays which are broader toward the 
papilla. Ebstein found isolated deposits in the cortex. The in- 
farctions consist of uric acid (Schlossberger). They are sup- 
posed to be due to the destruction of tissue rich in nuclein (cells) 
(Kossel and Horbaczewski). They are found in weaklings, and 
more often in infants who have been born living than in stillborn in- 
fants. During the first weeks of life they are washed out by the 
urinary secretion. Hence the increased uric acid excretion at that 
time. As a rule the condition gives no symptoms. It is not uncom- 
mon for the diapers of the infants to be stained red, and in older 
children there may be the so-called brick-dust deposit in the urine. 
In these cases there may be a history of severe colicky attacks. In 
other cases the infant or child experiences pain on urination and cries 
piteously. Some older children will run about in pain and grasp the 
penis. In all such cases I examine the diapers for concretions. Fail- 
ing to find these, I carefully examine the urethra. In several cases 
I have found an oval calculus of the size of a rice-seed, imbedded 
in the canal of the penile portion of the urethra. These cases have 
attacks of pain extending over months, and probably caused by the 
passage of the calculi from the kidney through the ureter, the blad- 
der, and urethra. The calculi are easily extracted with long-bladed 
forceps. In one of my cases of hseraaturia, in a boy three years 
of age, there were several attacks lasting for days, but no distinct 
history of pain. The urine contained blood coloring-matter, some 
blood-cells, and a few hyaline casts, which it was difficult to find. 
The diagnosis was obscure until a few small calculi were found in the 
urine. Urotropin given in small doses caused a cessation of symp- 
toms. 

ACUTE NEPHRITIS. 

A. Acute Parenchymatous Nephritis or Acute Exudative Ne- 
phritis (Delafield) ; Tubular or Glomerular Nephritis. 

B. Acute Diffuse Nephritis or the Acute Productive Nephritis 

(Delafield). 

The etiology of both forms of acute nephritis is the same. 
There is scarcely an acute infectious febrile disease which may 



ACUTE NEPHRITIS. 747 

not give rise to acute nephritis. It complicates or follows scarlet 
fever^ measles, influenza, diphtheria, infectious angina, pneumonia, 
rheumatism, typhoid fever, sepsis of all kinds, variola, parotitis, 
malaria, and congenital syphilis. The frequency in scarlet fever 
of the (edematous forms with anasarca has led to the belief that this 
disease was most often complicated by nephritis. If the paren- 
chymatous form is included, the condition will be found to be very 
frequent in other infectious diseases, but it is often unrecognized. 
The essential causes of acute nephritis are micro-organisms or their 
toxins. Thus in the various diseases, the Diplococcus pneumoniae, 
the typhoid bacillus, streptococci of various kinds, staphylococci, 
and the Bacillus pyocyaneus, have among other bacteria been found 
in the kidney. On the other hand, in diseases such as diphtheria, 
the toxins of the bacteria are the cause of the parenchymatous or 
diffuse nephritis (Fiirbringer, Roux, Councilman). If the toxins 
are formed in the body, the infections are said to be autochton or 
endogenous. The irritating toxin may be introduced from with- 
out, as in chloroform or ether narcosis, and the ingestion of drugs 
(ectogenous). The role played by cold as a causative factor is still 
a matter of speculation. Its mode of action, whether reflex, through 
the circulation, or by causing changes in the blood, is still obscure. 

Morbid Anatomy. — Acute Parenchymatous or Exudative Nephri- 
tis (Delafield). — This is an acute inflammation of the kidney, in 
which the principal changes occur in the epithelium of the tubules 
and Malpighian tufts. The kidneys are larger than is normal, and 
succulent. The capsule can be stripped from the surface, which is 
red, grayish, and punctate in spots. All the changes are most 
marked in the cortex of the kidney. Evidences of inflammation 
are found in the tubes, stroma, and glomeruli. The epithelium of 
the tubes is flattened, granular, and fatty, or in a condition of coag- 
ulation-necrosis. The lumen of the tubules may be empty or may 
be filled with desquamated epithelium or with coagulated masses 
(casts) of a hyaline character. Delafield describes the tubes, in severe 
cases, as filled with leucocytes and blood-cells. The tubes may be 
uniformly dilated. 

The changes in the glomeruli may be so slight as to be scarcely 
noticeable. The cavities of the capsules sometimes contain coagu- 
lated matter and red and white blood-cells (Delafield). In marked 
cases, there are desquamation of capsular epithelium and increase of 
nuclei. The swelling and proliferation of cells sometimes change the 
appearance of the tuft so that the outlines of the individual capillaries 
are lost. The stroma is infiltrated with serum, and in severe cases 
there are in the cortex small collections of white blood-cells (pus). 

The changes in acute diffuse nephritis, or the acute productive 
nephritis of Delafield, are more serious and permanent. According 
to Delafield, the kidneys are large, and at first smooth and later 
rough. The cortex may be mottled yellow and red ; the pyramids 



748 DISEASES OF THE KIDNEYS. 

are red. In this form of nephritis there are the changes found in 
exudative nephritis, and also a growth of connective tissue in the 
stroma and an increase of the capsule cells of the Malpighian bodies. 
These changes involve symmetrical strips in the cortex, which follow 
the lines of the arteries (Delafield). The Malpighian bodies show 
an enormous growth of capsule cells with compression of the tufts. 
If the nephritis is acute, the interstitial tissue is augmented with 
newly formed cells and basement substance. There is a new growth 
of connective tissue between the tubules ; the walls of the arteries 
are thickened. In the capsule of the Malpighian tuft, there is a 
growth of cells which compress the tuft of vessels. These and the 
vessels are in turn converted into small balls of fibrous tissue (Dela- 
field). In addition there may, in the acute forms of nephritis, be 
hemorrhages throughout the kidney substance. 

Symptoms. — In the forms of parenchymatous nephritis which 
complicate the febrile infectious diseases, influenza, pertussis, angina, 
and gastro-enteritis, either the symptoms of the primary disease 
mask those due to the kidney lesion or the nephritis may be so mild 
as to give no symptoms. Thus in the parenchymatous nephritis 
which complicates or follows influenza, there are after the attack has 
passed no symptoms referable to the kidneys, yet on examination 
the urine shows a trace of albumin, hyaline and a few epithelial 
casts, and an occasional red blood-cell. In these cases there is no 
oedema of the tissues, no headache, and the children are apparently 
well except for the changes in the urine. These may at first be 
quite marked. After a few months the albumin may only appear 
occasionally ; the casts and blood disappear for weeks and then 
reappear. For weeks or months the children may have no consti- 
tutional symptoms. In the parenchymatous nephritis, which is seen 
in severe forms of gastro-enteritis and dysentery, the signs in the 
urine of marked nephritis are albumin, casts of all kinds, and 
blood-cells (Parrot, Fischl, Czerny, Koplik, and Morse). Although 
Czerny traces a certain form of dyspnoea to the influence of uraemia 
in these cases, no distinct set of symptoms due to the kidney can 
yet be formulated. It is true that there are terminal anasarca, sup- 
pression of urine, and vomiting, but the presence of all these may 
be explained by the severity of the intestinal lesions. 

Changes in the Urine. — In all the diseases above mentioned, the 
parenchymatous nephritis may in infants and children be evinced by 
diminution of the quantity of urine, or the presence of a trace of 
albumin, or a few hyaline or epithelial casts and blood-cells. The 
quantity of urine may, however, be normal. In other cases, the 
albumin is more marked and the casts much more numerous. Renal 
epithelium is also present. Leucocytes are rare. 

In the diffuse or productive form of nephritis in infants and 
children, the symptoms are marked. In some forms of nephritis 



ACUTE NEPHRITIS. 749 

complicating scarlet fever the lesion never advances beyond the 
parenchymatous stage, and at that period the symptoms are either 
not present or not noticeable. If the nephritis is more marked, 
however, it is noticed at the end of the third week that the patient 
is somewhat pale, that the face is a little swollen especially about 
the eyes, and that there is very slight oedema of the general surface. 
In these cases it is possible at the end of the period of eruption, 
to find a slight trace of albumin in the urine and a few hyaline and 
epithelial casts. With the onset of the anasarca the albumin 
increases in quantity, the casts in number, and a few blood-cells are 
found. The quantity of urine is diminished, but in the mild forms 
not markedly so. A boy of six years may pass half the normal quan- 
tity. There is no headache, and only a few obscure pains in the 
joints. There is occasionally slight pain in the region of the 
kidney. The temperature is normal or may at intervals of several 
days rise a degree or a degree and half above the normal. The 
nephritis is probably of the mild diffuse type. In three weeks the 
mild anasarca disappears, the anaemia improves, and the urine be- 
comes normal. 

In the more severe cases there is a rise of one or two degrees 
in temperature, and the patients have marked general anasarca. If 
old enough, they complain of headache, they vomit, and show marked 
decrease in the number of respirations and pulse, the irregularity 
of pulse being of a purely ursemic character. In some cases there 
are effusion into the chest (hydrothorax) and abdominal ascites. 
The quantity of urine is much diminished, there being only one 
or two ounces in twenty -four hours. The specific gravity is high ; 
the urine contains blood, leucocytes, and casts (hyaline, granular, 
and epithelial), with blood cells. Under treatment, the vomiting, 
headache, and anasarca subside, the quantity of urine increases, the 
number of casts and blood-cells diminishes, and the patient makes 
a good recovery. In other cases the initial anasarca becomes more 
marked, there being considerable oedema of the whole surface ; the 
urine is entirely suppressed ; the vomiting and headache increase ; 
convulsions set in ; there are several attacks of eclampsia ; the 
patient becomes comatose, and may die of uraemia, or after one or 
two attacks of eclampsia, the symptoms may abate and recovery 
take place. 

There is a very fatal form of diffuse nephritis which occurs on 
the fourth or fifth day of malignant scarlet fever. On the third day, 
at the height of the eruption, the patient passes into a delirious, 
semi-conscious state. The quantity of urine is much diminished ; 
its specific gravity is high ; casts of all kinds and blood are present. 
The urine may finally be totally suppressed. There is no oedema of 
the surface. Coma and convulsions set in. The patient succumbs 
to the intense general toxaemia and to its effect on the kidneys. In 



750 DISEASES OF THE KIDNEYS. 

these cases the kidney symptoms cannot be separated from those 
caused by the general intoxication. 

Individual Symptoms. — The Vomiting. — The vomiting in scar- 
latinal nephritis is rarely distressing, and subsides in a short time. 
It is not a constant symptom, nor is it of serious import. 

The HEADACHE is not a very marked symptom in children. 

(Edema is present in a large proportion of cases, and is marked 
in the severe ones. It may occur with hydrothorax, ascites, and 
hydropericardium. It may affect only the face, or the lower extrem- 
ities alone. It may be so intense as to cause bursting of the skin 
and the escape of serum through the fissures. It may affect one 
half the body more than the other (Henoch). Under all these con- 
ditions, the outlook is serious. 

The PULSE is sometimes inordinately slow. It may be more 
rapid than normal, and may show marked irregularity. 

The HEART may, as was pointed out by Henoch and Friedlander, 
be the seat of hypertrophy and dilatation. There may be compli- 
cating endopericarditis. 

The LUNGS may be the seat of pneumonia, or oedema of the 
lungs may suddenly develop. There may be complicating pleuritis. 

There may be constipation or more or less diarrhoea. 

There are cases in which the temperature is normal or sub- 
normal during the whole course of the disease. In the cases in 
which there are sudden eclamptic seizures, the temperature may mount 
to 104° F. (40° C.) during the attacks. On account of the rupture 
of a bloodvessel in the brain during the eclamptic seizures, there is 
in many cases, after the subsidence of the ursemic symptoms, aphasia, 
or hemiplegia of a more or less permanent nature. 

Patients with nephritis succeeding scarlet fever develop fainting 
spells with cyanosis, galloprhythm, and all degrees of cardiac weak- 
ness. It is difficult in such cases to know whether to attribute 
these symptoms to the nephritis or to myocarditis which is the 
result of the scarlet fever. 

The Urine. — The general characteristic features of the urine in 
acute diffuse nephritis of scarlet fever have been given. Suppression 
may take place suddenly. The urine may not have contained coagu- 
labie albumin or casts, and the quantity may have been normal. 
The common notion that uraemia or eclampsia can supervene only if 
the quantity of urine is diminished, is erroneous. Even if the 
quantity is above the normal and the urine contains little albumin 
and few casts, eclampsia may supervene with fatal results. An in- 
crease in the quantity of urine above that of the normal is an 
unfavorable symptom. The quantity of urea passed is always the 
crucial test. There are cases in which blood appears in the urine 
and in which there is true hsemoglobinuria, which may give rise to 
irritation of the kidney. In other words, the hsemoglobinura is 



CHRONIC DIFFUSE NEPHRITIS. 751 

primary, the nephritis secondary. The quantity of albumin in the 
urine varies greatly ; it may only amount to a trace or be sufficient 
to cause the urine to become solid when boiled. 

The Primary Forms of Acute Nephritis. 

The question has arisen : Can nephritis be primary ? If nephritis 
is the result of some form of infection, it cannot be primary. 
Henoch, Heubner, Bouchut, Bartels, Loos, and Holt have published 
cases in nurslings, the origin of which could not be traced. These 
occurred in infants from five weeks to one and a half years of age, 
who suddenly developed marked anasarca and vomiting, with sup- 
pression of urine. Some of the cases had a febrile movement of a 
remittent type. The majority of them were fatal. Their exact 
nature is still unknown. Uhlenbrock has recently collated all the 
cases in the literature, but has thrown no light on the subject. On 
autopsy, a few cases have shown a parenchymatous nephritis. 

Course. — The majority of cases of parenchymatous or exudative 
nephritis recover. The prognosis of the diffuse or productive form 
is more serious, but in exceptionally mild cases recovery may take 
place. Other cases make an apparent recovery. After the symptoms 
of oedema and anasarca have disappeared, anaemia remains. The 
albumin in the urine may disappear and reappear. In six months 
or a year, general anasarca may set in with all the symptoms of an 
acute exacerbation of the disease. The patient may eventually re- 
cover from the attack, but as a rule others of the same kind follow, 
and the condition of chronic nephritis results. 

Duration. — The acute forms of parenchymatous or diffuse neph- 
ritis last from two to six weeks. The parenchymatous forms are 
sometimes evanescent, the marked symptoms lasting only a week. 

Chronic Diffuse Nephritis. 

(a) Chronic Productive Nephritis, (6) Chronic Nephritis without £'xMC?a^j'o?i(DELAFiELD). 
The forms of chronic diffuse nephritis are the same in childhood 
as in adult life. They usually occur late in childhood. Thus one 
case of chronic diffuse nephritis in a girl of fourteen years of age 
dated from an attack of scarlet fever at the age of eight years. 
At autopsy there was found a diffuse nephritis of the productive 
variety (large white kidney). In another case, a boy of twelve 
years, with diffuse nephritis of the non-productive variety (small 
cirrhotic kidney), had had an attack of scarlet fever at the age of 
five years. He had no anasarca in the course of the nephritis. 
Active symptoms of headache and vomiting appeared a year and a 
half before his death. The quantity of urine was above the normal 
and there were a few hyaline casts. At autopsy a small kidney was 
found. Thus there may in children be two forms of chronic nephri- 
tis following scarlet fever or any other infectious disease. Adults 



752 DISEASES OF THE KIDNEYS. 

present symptoms referable to the eye, such as neuroretinitis, which 
I have not met with in children, and which must be exceedingly 
rare. Neither have I seen in children the emphysema met in 
adults. The heart may be hypertrophied and dilated in children 
as in the adult. They may have endocarditis and pericarditis with 
pleurisy. 

Treatment. — The forms of parenchymatous or exudative neph- 
ritis which so frequently occur as accompaniments of the acute 
febrile disorders, pneumonia, typhoid fever, influenza, etc., need little 
or no treatment. There are no symptoms referable to the kidney. 
Nephritis accompanying acute gastro-enteritis is best treated by 
remedies directed toward the primary affection. The quantity of 
urine is sometimes diminished. It contains casts of all kinds. 
Rectal enemata of saline solution at a temperature of 108° F. 
(42.2° C.) are then of great utility, not only in supplying fluid to 
a depleted circulation, but also in stimulating the circulation and 
therefore the kidney secretion. Drugs which might still further 
compromise the condition of the kidney should not be given for 
the intestinal affection. Hot baths are of great utility, 105° F. 
(40.5° C). 

In the partial or complete suppression of urine seen in the first 
few days of the malignant forms of scarlet fever, more active treat- 
ment is required. When the temperature is high, the pulse rapid 
and weak, the patient unconscious or delirious, and the urine dimin- 
ished or suppressed, I administer high and large rectal enemata of 
water at a temperature of 108° to 110° F. (42.2° to 43.3° C), as 
recommended by Kemp. These should not be given to children 
with a double-current tube, but simply as enemata. About a quart 
of saline solution is thrown into the rectum at very low pressure. 
A fountain bag syringe is utilized for this purpose. These enemata 
stimulate the heart and circulation and supply the system with 
normal fluid. To stimulate the skin, the warm baths are preferable 
to cold ones. Patients are frequently much depressed by cold packs 
or baths given to reduce the temperature. The temperature of the 
bath should be at least 105° F. (40.5° C), and the patient allowed 
to remain in it five or ten minutes, according to the state of the 
pulse. 

In acute cases the anasarca will, as a rule, take care of itself. If 
it is extreme. Senator advises the administration of diuretics in acute 
as well as chronic nephritis. Some authors recommend diuretin and 
digitalis in form of infusion, a drachm being combined with an agree- 
able alkali, such as citrate of potassium. The pulse should be 
watched. If it is low, the digitalis is suspended. I do not utilize 
whiskey or alcohol in these cases. In acute diffuse nephritis and 
in productive nephritis similar to that of scarlet fever, the ursemic 
symptoms, the oedema, and the kidneys are treated. Vomiting 
is a ursemic symptom which is prominent at first. If the patient 



CHRONIC DIFFUSE NEPHRITIS. 753 

vomits everything ingested, no food should be given by mouth. 
The patient is nourished by rectum by means of somatose or 
nutritive enemata. The headache needs little treatment. Bromide 
and a small dose of chloral or trional are given for restlessness at 
night. In the forms of nephritis, generally subacute, in which there 
are oedema amounting to anasarca, and diminution of urine, baths 
and diuretics are beneficial. The anasarca is sometimes scarcely 
noticeable, and the quantity of urine little diminished. There are 
usually a few hyaline and epithelial casts, and also blood-casts. The 
patient is kept in bed and put on a milk diet. The bowels are kept 
open by means of Vichy water given in liberal quantities, or by 
Carlsbad salts. A child between four and six years of age should 
take half a drachm of the salts once a day. Some mild diuretic, 
such as citrate or acetate of potassium, is given. The pulse may 
be 80 or 90, and digitalis is therefore not given. Under this mild 
therapy the anasarca subsides, the albumin diminishes, and the urea 
and quantity of urine increase. Milk also tends to increase the 
quantity of urine. A bath at 104°-105° F. (40° C) is given every 
day or every second day according to the indications. The diaphoretic 
effects of vapor baths are less marked. In some of the severer cases 
the urine is greatly diminished, the anasarca extreme, the pulse 
and respirations are increased, and the temperature may be elevated. 
The anasarca is then treated by a daily warm bath, in which the 
patient remains for five minutes, and is then wrapped in a warm 
dry blanket to promote diaphoresis. A warm rectal enema at the 
temperature above mentioned is given twice daily. The kidneys 
are stimulated by means of digitalis and acetate, citrate, or tartrate 
of potassium. The digitalis is given in form of the infusion, 3ss— 3J 
with 3 to 8 grains of the potassium salt, three or four times daily. 
The pulse is closely watched and not allowed to fall too low. The 
bowels are kept open by the daily administration of cathartics. If, 
as frequently happens, the heart becomes weak, sparteine or liq. 
ammonise acetatis and nitroglycerin may also be given. I do not 
administer preparations of musk or camphor in nephritis. Con- 
vulsions are best controlled by means of chloroform. Warm baths 
and high warm enemata are also useful. Bromide and chloral are 
also given by rectum, as in ordinary eclampsia. 

In convalescence the question arises. When shall diuretics be dis- 
continued ? As soon as the quantity of urine is above the normal, 
they are of no further value. The baths and enemata are continued 
as long as there is the least oedema of the surface. Warm enemata 
should not be continued after the urine has increased to the normal 
amount. Ordinary enemata are then given for the purpose of aiding 
the cathartics in keeping the bowels open and clear of fecal accu- 
mulations. 

Rest in bed should be continued until there is no palpable albu- 
48 



754 DISEASES OF THE KIDNEYS. 

mill reaction. Meat and vegetables are then added to the diet list. 
If anaemia is present, a readily assimilable form of iron, such as the 
peptonate, is given. Casts will appear in the urine far into conva- 
lescence. The patients may, however, be allowed to be up if they 
bear the change well. A too protracted stay in bed is sometimes 
exhausting in summer. If symptoms of anasarca and other signs 
of nephritis recur, the treatment is the same as in primary acute 
attacks. The treatment of chronic nephritis in children does not 
differ from that followed in the adult. I have recently subjected two 
children who suff'ered from the chronic diff'use form of nephritis fol- 
lowing scarlet fever, accompanied by recurrent attacks of anasarca 
extending over years, to Edebohl's operation of splitting or extirpation 
of the kidney capsule. Both cases w^ere much benefited by the opera- 
tion. One case is now free from symptoms for fully a year. If we 
can improve these cases to this extent, the operation is certainly indi- 
cated, even if the operation is powerless to restore the kidney to the 
normal. 

NEW GROWTHS OF THE KIDNEY. 

Thirty-eight per cent, of all the reported cases of kidney tumors 
occurred in children (Doderlein, Lewi). The following growths are 
here considered : 1 . Cysts of the kidney ; 2. Tuberculosis of the 
kidney ; 3. Carcinoma of the kidney ; 4. Sarcoma of the kidney. 

Cysts of the Kidney. 

Cysts of the kidney are in children usually of congenital origin. 
They are formed in the second half of intra-uterine life. They are 
bilateral, only 1 in 60 being unilateral (Lejars). The kidney is 
made up of greater and smaller cysts. The cystic formations may 
be present to the entire exclusion of kidney tissue. The cysts may 
attain the size of a child's head and seriously obstruct delivery. 
They are of anatomical interest only, since infants with such cysts 
present other abnormalities and die soon after birth. 

Hydronephrosis. 

Hydronephrosis is either congenital or acquired. If acquired, it 
occurs late in childhood. The congenital form is due to stenosis in 
some part of the urinary tract. Hydronephrosis is as a rule uni- 
lateral. If it occurs after birth, it may be due to obstruction by 
calculi or to uric acid infarction of the kidney. The healthy kidney 
is physiologically enlarged. The acquired form is due to obstruc- 
tion by calculi or to tumors pressing on the ureters. At first the 
pelvis of the kidney, then its tissue is encroached upon in the 
gradual dilatation. Finally the shape of the kidney is lost. There 
is a large fluctuating tumor which may or may not be painful. 



PLATE XXVIIL 




Sarcoma of the Kidney. Child six years of age 
Irregular contour of the abdominal tumor. 



CARCINOMA OF THE KIDNEY. 755 

When it is punctured, there is withdrawn a fluid which contains 
albumin, epithelium, urea, uric acid, and which has a low specific 
gravity. In some cases there occurs what is known as intermittent 
hydronephrosis. The contents of the tumor are emptied spontane- 
ously, but reaccumulate. The diagnosis rests on the presence of a 
fluctuating tumor containing the fluid, and urine constituents. 
Cystoscopy may in some cases reveal obstruction of the ureters. 

Cysts must anatomically be differentiated from the condition 
of hydronephrosis. Cysts are new growths (Senator) ; in that 
respect they differ from the cystic condition of hydronephrosis. It 
is not possible clinically to differentiate congenital cysts of the 
kidney from congenital hydronephrosis. 

Sarcoma of the Kidney. 

Sarcoma of the kidney occurs in children as a primary growth. 
In the statistics of Rosenstein and Senator two-thirds of the cases 
occur before the tenth year. It is more frequent in females. The 
left kidney is more commonly affected. Sarcoma occurs in the newly 
born infant. The presence of muscle, bone, and cartilage tissue in 
these growths supports the theory of their congenital origin (Jacobi). 
The anatomical nature of the growth varies widely. It may be 
round-celled or spindle-celled sarcoma, a fibro-sarcoma, myo-sarcoma, 
angio-sarcoma, melanotic sarcoma, or adeno-sarcoma. There may be 
metastases. The tumors sometimes attain a weight of fifteen pounds. 

The symptoms do not differ materially from those of carcinoma 
of the kidney, nor is sarcoma of slower growth. In many cases the 
pain, hsematuria, and tumor follow a traumatism. Hsematuria is 
not, as in carcinoma of the kidney, a constant symptom. I have 
seen cases of both carcinoma and sarcoma of the kidney in young 
children without hsematuria or growth elements in the urine. Ascites 
is present in more than one-half the cases (Lewi). 

Diagnosis. — A malignant growth in a child may be surmised to 
be a sarcoma, since those growths are more frequent in children than 
carcinomata. Swelling of the lymph-nodes may be present in 
sarcoma as well as in carcinoma. Histological elements in the 
urine are rare. Von Jaksch has mentioned the presence of small 
round cells (sarcoma cells), but their significance is not as yet 
determined. Puncture for diagnostic purposes is dangerous, and 
if performed at all should be done posteriorly in the lumbar region 
(extraperitoneal). In sarcoma of the kidney, as in all growths of that 
organ, the colon is pushed in front of the growth (Plate XXYIIL). 

Carcinoma of the Kidney. 

Of 449 cases of carcinoma of the kidney (Rohrer, Ebstein, 
Lachman), 157, or almost 35 per cent., occurred in children under 
the tenth year. Monti tabulated 50 cases, and found that more than 



756 



DISEASES OF THE KIDNEYS. 



50 per cent, occurred in children under the age of two years. The 
youngest patient was twelve months of age. It is more frequent in 
males. As a rule the right kidney is affected. In children, the growth 
is apt to attain great size. Guillet found that the average weight 
was eight and one-half pounds. By reason of the great weight of the 
growth, the kidney may sink from its normal position and lie trans- 
versely across the vertebral column. The growth is a primary one, 
The medullary carcinoma is the prevailing type ; the scirrhous is 
next in order of frequency. The disease may be secondary to carci- 
noma of the suprarenal capsule or of the retroperitoneal glands. The 
liver, the lungs, and the inguinal lymph-nodes may be secondarily 
involved. 

Fig. 163. Fig. 164. 




Enlargements of the kidney. 

Anterior palpable tumor beneath the liver. Posterior area of flatness in the lumbar 

region, giving a palpable tumor between the 
border of the ribs and the crest of the ilium. 



Symptoms. — The chief symptoms are pain, hsematuria, cachexia, 
and enlargement of the kidney. Guillet found that hsematuria was 
the first symptom in one-half the cases. The quantity of blood 
passed may be very small, or so great as to amount to a dangerous 
hemorrhage. The urine may be red or chocolate colored, and may 
contain clots of blood or casts of the ureters. Frequent micturition 
is sometimes an early symptom. In other cases there is no hsema- 



TUBERCULOSIS OF THE KIDNEY. 757 

turia, the cachexia, emaciation, and tumor being the first symptoms. 
In younger children the hsematuria is frequently absent. The kidney 
is in these cases protected from traumatism. The tumor is some- 
times so great as to cause displacement of the organs. In Fiirbrin- 
ger's case the heart was displaced to a situation beneath the clavicle. 
The abdomen is distended, and the colon is pushed in front of the 
growth and is indicated by a tympanitic area at one side of the 
median line of the tumor. On the right side, the tumor appears 
beneath the liver, and in narcosis can be felt in tliat situation as a 
distinct mass. The tumor has an uneven surface. The urine may, 
in addition to blood, contain histological elements of the growth. 
This does not occur so frequently in carcinoma of the kidney as in 
tuberculosis of that organ. 

Duration. — The progress of the growth is much more rapid 
in children than in adults. In the former subjects the duration of 
the disease is from ten weeks to fourteen months (Roberts). 

Diagnosis. — In children, while the diagnosis of a morbid growth 
of the kidney can be made, it is not possible to differentiate be- 
tween the symptoms of carcinoma and those of sarcoma. It can- 
not be determined, from the symptoms, whether the growth is a 
simple carcinoma, an adeno-carcinoma, or an adeno-sarcoma. The 
symptoms of a malignant growth of the kidney are pain, hsematuria, 
tumor, and cachexia. A cyst of the kidney may be confounded 
with a malignant growth. Cysts are congenital, and as a rule 
bilateral. This is also the case in hydronephrosis. In the latter 
condition extraperitoneal puncture of the tumor may give a fluid 
with urine constituents. In carcinoma of the kidney, puncture for 
diagnostic purposes is not devoid of danger. 

Tuberculosis of the Kidney. 

Tuberculosis of the kidney is rarely if ever primary. Senator 
asserts that it never occurs as a primary lesion. There are patho- 
logically two forms — the miliary and the cheesy. The miliary 
form is more frequent in children, the cheesy in later life. In 
the miliary form, the kidney tissue is the seat of an eruption of 
miliary tubercles. In the cheesy form, tuberculous nodules may 
entirely replace the substance of the organ. The cheesy form is as 
a rule secondary to tuberculosis of the genitals — the epididymis in 
boys and the tubes in girls. The symptoms do not differ materially 
from those of the same condition in adults. In the miliary form 
there are no symptoms. In the cheesy variety there are dysuria, 
strangury, vesical tension, pain in the region of the kidney, 
emaciation, and fever. The urine contains albumin, blood, epi- 
thelium, and pus cells, and is acid in reaction. Tubercle bacilli are 
sometimes found. 



758 DISEASES OF THE KIDNEYS. 

The diagnosis rests on the presence of tubercle bacilli in the 
urine, an enlarged palpable kidney, hsematuria, and tuberculosis of 
other organs — the genitals or the lungs. 



Treatment of New Growths of the Kidney. 

The treatment of new growths of the kidney is within the prov- 
ince of the surgeon. The congenital cysts are of scientific interest 
only. If there is reason to believe that there is congenital hydrone- 
phrosis Avhich is unilateral only, surgical interference is indicated. 
Sarcomata and carcinomata should be treated surgically if there is 
reason to believe that there are no metastases in the liver or else- 
where. Tuberculosis of the kidney is treated more from a general 
standpoint. If there is tuberculosis elsewhere, palliative treatment 
alone must suffice. Isolated tuberculosis of one kidney is a rare 
condition which necessitates extirpation of the organ. If it is 
impossible to determine the proper treatment, an exploratory opera- 
tion is indicated. 



Pyelitis — Pyelonephritis. 

This is a very rare affection in infancy and childliood. Calculus, 
tuberculosis, and irritating drugs, are etiological factors. It occurs 
as a complication of the infectious diseases — scarlet fever, measles, 
variola, and typhoid fever. It may be caused by infection from a 
vulvovaginitis or by coli bacteria entering through obscure chan- 
nels. The inflammation of the pelvis of the kidney may extend 
to the tissue of the kidney 'itself. Small abscesses are present 
in the cortex and there is degeneration of the parenchyma of the 
kidney. 

The symptoms consist of fever, of an intermittent or remittent 
type, with recurrent rigors. The fever may alternate with sub- 
normal temperatures. The urine is characteristic. It is of normal 
quantity, and low specific weight, is acid in reaction, milky in 
appearance, and contains pus, mucus, and albumin. Microscopi- 
cally there are casts, leucocytes, and bacteria. The bacteria present 
in recently voided urine include the coli group. Bacterium lactis, 
proteus, and Bacillus pyocyaneus (Baginsky). It is characteristic 
of this condition that the pus may suddenly disappear from the 
urine through occlusion of the ureter on the affected side by calculi, 
fibrin, or inspissated mucus. It may reappear after a time. Ema- 
ciation and periarticular or intermuscular inflammation are also 
sometimes present. 

Prognosis is influenced by the causal agent. Simple coli-pyeli- 
tis may retrograde within a few weeks and result in recovery. The 



ENUBESIS NOCTURNA AND DIUENA. 759 

chronic form may last for months. Other forms may lead to irre- 
parable inflammation and degeneration of the kidney. 

Treatment. — If the condition does not improve under treatment 
of rest, milk diet, and diuretics, surgical interference may become 
necessary. 

PERINEPHRITIS AND PARANEPHRITIS. 

This condition is rare in infancy and childhood. It is not 
always possible to determine the cause. If such is the case, the 
disease is called primary. As a rule, it is secondary to traumatism 
in the lumbar region, to pyelitis, or to pyelonephritis. It may 
occur in septicopysemic processes, and I have seen it follow the in- 
fectious diseases, notably scarlet fever. Of 166 cases collected by 
Nieden, only 26 occurred in children. One case occurred in an 
infant five weeks old. Gibney's cases ranged from one and a half 
to ten years of age. The condition is more common on the left side. 
The pus may burrow behind the liver or spleen, or find its way 
downward, forming a mass simulating a cold abscess or a peri- 
typhlitic abscess. It may perforate into the pelvis of the kidney, 
the intestine, peritoneum, vagina, or diaphragm, or, may pass along 
the ileopsoas muscle, and find its way to the hip, and thus appear 
externally. The kidney may be involved because of its contiguity 
to the seat of the process. Pleuritic metastases and amyloid degen- 
eration may finally result. 

The symptoms are usually obscure. The fever is intermittent 
or remittent. Young children do not as a rule complain of pain. 
The first intimation of the nature of the disease is the appear- 
ance of a swelling in the lumbar region. On bimanual palpa- 
tion, a tumor which is fixed, tense, and does not move with respira- 
tion, is felt deep under the liver, in the region of the caecum and 
ascending colon on the right side, or underneath the spleen on the 
left. Gibney has described these cases and shown how they may be 
easily mistaken for cases of cold abscess. The thigh of the affected 
side is held in a condition of semiflexion. 

The treatment is surgical. 



ENURESIS NOCTURNA AND DIURNA. 

This is a functional neurosis of the bladder in which the urine 
is passed involuntarily, and, as a rule, at night during the first hours 
of sleep. It may, however, be passed at any time during the night. 
Some patients have at times no control over the bladder during the 
day (diurna). Some have enuresis every other night or only once 
or twice a week, and others suffer from the affection every night. 



760 DISEASES OF THE UROGENITAL TRACT. 

Cases of enuresis should be differentiated from those in which there 
is a complete paresis of the sphincter vesicae. In the latter case the 
urine simply flows away. These are cases of disease or anomaly 
of the cord (spina bifida). In enuresis the children may in other 
respects be in good health. There is frequently a nervous condition. 
In some cases there is lithiasis or stone in the bladder ; in others the 
etiological factor is Oxyuris vermicularis, obstipation, tumor of 
the bladder, or vulvovaginitis. Cystitis and adenoids have been 
regarded as causal. In the majority of cases no cause can be found. 
The condition follows the exanthemata. In boys it usually disap- 
pears toward the sixteenth year. I have seen it persist in girls 
into adult life. Its treatment becomes a very serious problem. 

The diagnosis is not difficult. The urine should be carefully 
examined for evidences of lithiasis, cystitis, glycosuria, nephritis, and 
nematodes, and the bladder for stone. The diagnosis is not made 
in infants and very young children. In the latter the enuresis is 
often only apparent. They do not know how to indicate their 
wants. 

Treatment. — The urine should be passed before retiring. The 
patients should take little liquid at the evening meal. The foot of 
the bed is raised so that the head is slightly lower than the ])elvis. 
The drugs most utilized are ergot and atropine. The former is 
given in the fluid extract, minims x to xxx (0.6 to 2.0) t. i. d. Atro- 
pine is given before retiring in a solution (grain j to 51) ; 0.06 to 30.), 
a drop for every year of the age (Watson). It is efficient in many 
cases, but in some children distinctly dangerous, I had one case 
in which I gave one-half the above dose. The child, five years of 
age, became slightly delirious and tried to walk out of a window. 
Many cases will improve, only to be subject to relapses. Marion 
Sims has shown that enuresis in young girls may be due to an 
intolerant and very small, contracted bladder. In such cases, he 
advises gradual dilatation of the bladder by injecting the organ 
with increasing quantities of an indifferent fluid. If treated in 
this way, the bladder will eventually retain urine. Most of the 
cases resist all methods of treatment. 



VULVOVAGINITIS. 

( Urogenital BlennorrhGea.) 

The term vulvovaginitis, or, as it is now called, urogenital blen- 
norrhoea, refers to a gonorrhoeal inflammtition of the genital tract in 
children. Before describing the condition it is necessary to refer to 
catarrhal conditions which are not gonorrhoeal, and which are present 
in the normal state. 

Epstein has shown that in the newly born infant there is a 



VULVOVAGINITIS. 761 

physiological and normal discharge from the vagina. It is an adhe- 
sive, mucoid discharge containing epithelial cells and micro-organ- 
isms. A few days after birth, this discharge assumes a purulent 
and, in icterus, an icteric hue. No leucocytes are found in the dis- 
charge. In two weeks it ceases and the parts appear normal. This 
form is not gonorrhcieal. A second condition which I have noted in 
very young children is the result of uncleauliness, lithiasis, irritation 
caused by Oxyuris vermicularis, or masturbation. The parts are 
reddened and eroded, and are bathed with an abnormal serous dis- 
charge. There may be a few erosions around the introitus. These 
cases recover with ordinary care and removal of the source of irri- 
tation. Pus is rarely secreted. 

A second group of cases occurring in young female children 
includes those of vulvovaginitis of the simple catarrhal type. These 
have a scanty or ])rofuse purulent discharge from the vagina, vulva, 
and urethra, which ])resents clinically all the features of the specific 
gonorrhoeal group, but is not gonorrhoea! . The condition is not of 
infrequent occurrence. The urethral orifice is swollen and red. The 
hymen is also swollen and inflamed. The discharge is thin and 
milky, or greenish and viscid. Microscopically, it shows in the pus- 
cells bacteria and diplococci in groups, but these do not show either 
by culture or on staining the characteristics of the gonococci. The 
history of such discharges is singularly similar to that of the gonor- 
rhoeal form. Urination is painful, and the discharge persists even 
under careful treatment. In one case of this kind I have seen an 
inguinal bubo. The catarrh, like the gonorrha^al form, affects the 
urethra, vulva, vagina, and cervix uteri. I am convinced that the 
discharge is infectious and connnunicable from one child to another. 
It may last for months and again recur. Its exact etiology 
is still unknown. Uncleauliness, infection from a vaginal dis- 
charge, marasmus, the infectious diseases, or frail health may be 
the cause. 

Urogenital Blennorrhoea. — These cases have been described by 
Pott, van Dusch, Spaeth, Cahen-Brach, Epstein, and others. 

Etiology. — This form may occur in newly born infants (Epstein) 
or in older infants and children. Epidemics may occur in hospitals 
(Fninkel). The avenue through which the disease is conveyed is 
still unknown. It occurs in all walks of life. In some cases there 
is a history of the child^s having slept with the mother. In others, 
there is no such history. I have sometimes obtained a history of 
an abnormal attempt at coitus between boys and girls, the boys 
having suffered at the time from gonorrhcea. Such cases are, how- 
ever, exceptional. The exciting cause is the gonococcus (Neisser) 
(Fig. 165). This micro-organism has been found in the discharges 
of all these cases, and cultivated (Koplik, Heiman). 



762 



DISEASES OF THE UROGENITAL TRACT. 



Symptoms. — There is a thick, viscid, ])iiriilent, greenish or yel- 
lowish discharge from the vagina, whicli bathes the parts and dries 
in crusts on the labia. The opening of tlie urethra is reddened and 
swollen. There is a discharge from tlie urethra. Micturition is 
painful. In some cases there are slight swellings of the inguinal 
lymph-nodes. If the speculum whicli is used for the male urethra 
is introduced into the vagina (Tuttle's urethral speculum), it is seen 
that the purulent discharge is present in the folds of the mucous mem- 
brane of the vagina. The cervix uteri also contains a drop of pus. 
Thus the whole genital tract is involved. Some cliildren complain 
of pain over the lower part of the abdomen. On examination, this 
is found to be pelvic, and is probably due to inflammatory reaction 
of the tissues about the uterus and vagina. 



Fig. 165. 




Gonococci in vaginal disoliarge. Cover-glass spread. Photomicrograph. X 1000. 

Complications and Course. — Tlie course of the disease is quite 
tedious, and may 0(;ciipy eight weeks, three months, or more. The 
discharge may abate, only to return in its original severity. 

Peritonitis has in rare cases been reported as a comjolication of 
this form of vulvovaginitis. It may prove fatal. Hunner and 
Harris recently reported a fatal case in a girl ten years of age. 
They collected 5 other cases from the literature occurring in chil- 
dren. Pelvic peritonitis occurred in 2 of my cases with the usual 
signs of pain and fever. Botli cases made a good recovery. 

Hartley and I have reported cases of arthritis complicating vulvo- 
vaginitis in children. My cases occurred in the first and second 
weeks of the disease. In one case, only one joint was affected ; in 
another, two. Both recovered without suppuration. 

Gonorrhoeal conjunctivitis may result from careless infection of 



IJKKTJIJUTl^ IN MALE CHILDREN. 763 

the c\yos. T have had only 2 cases in wliieli tlie ])aiients e()in])hiine(l 
of [)raxM)r(lial j)ain. In iieithcM' were there active^ symptoms of eiuh)- 
periearditis, but th(M'e is no rc^ason why it. mio-ht not ocieur in eliil- 
dren, as in adults. 

Sanger at one time* ti-aced a eonneelion betwcHMi sttM'ility in later 
life Mnd attacks of this disease in ehihlhood. 

Treatment. — Prophyhixis is of oivat importance. A child 
affected witli the disease should not he allowed to sleep with otbCr 
children. Tlie toilet ap])liances should not be used by other children. 
The parents should be careCully (Mdiohtened conccM'uino- the infec- 
tious nature of the aifection and the oront dano-er to the eyesioht 
should infection of the eyes occur. The hands of the ])ati(Mit should 
be kept scrupulously clean. In institutions the |)atients should be 
strictly isolated. The vulva should be kept covered with a pad of 
absorbent gauzc^, and a (lia[)er should b(^ worn over this to [)revent 
the discharoe from soilino; the clothes. In the acute stage, the 
vagina should be irrigated with a glass catheter or a 8kene urethral 
catheter twice daily. The solution should be at a tem[)erature of 
108° F. (42.!2° C). The irrigating solutions should be either a 2 
per cent, solution of acetate oi' aluminum or a 1 : '2000 or a 1 1500 
solution of nitrate of silver. If the silver or aluniinuni solution 
is irritating, a simple saturated solution of boric acid may be used. 
In the subacute stage thcv vagina is painted every other day with a 5 
or 10 per (X'ul. solution of nitrntc ol' silver. A Tuttle urethral specu- 
lum is used loj" tlu^ purpose. If (he child is intractable^ it is impos- 
sible to do this without the use of an antiosthetic, which, however, 
seems scarcely justifiable. I have cured these cases with rest in 
bed and irrigations. I have tried the bougie treatment and the pro- 
targol and permanganate of potassium irrigations, but have found 
the treatment above described [)re(eral)le. 

URETHRITIS IN MALE CHILDREN. 

8impl(^ urethritis of the antci'ior portion of the urethra occurs in 
infants and young children. It is caused either by unnatural inter- 
ference with the parts or infection. It is not gonorrlux'al. The 
meatus is slightly nul or the [)arts are ngglutinatcd willi dried pus. 
On pressure^, a drop of pus exudes from llu* urethra. TIkm-c is ardor 
urinje, due to a, slight iissuration of the meatus. The affection is 
easily cured by attention to cleaidiness. An alkali, such as citrate of 
potassium, is given in very small doses, to alk^viate the ardor uriuix). 

(Jonorrlux^a oc(Mirs in male infants and boys, and is tlu* result of 
dircH'-t infection. The symptoms are much the same as in adults, 
e.\(^e[)t that, as a rule, there are no c()mj)lications. Balanoposthitis 
and lym])hadenitis may occur, also epididymitis, and rarely orchitis. 
J5okai I'eports cases of stricture. 



764 DISEASES OF THE UROGENITAL TRACT. 

CYSTITIS. 

Cystitis is not very common in infants and children. Attention 
has recently been drawn to this affection by Escherich, who reported 
several cases of cystitis in young female children caused by coli 
bacteria. 

Etiology. — Barlow classifies cases of cystitis as follows : 

{a) Chemical cases, caused by drugs. 

(6) Bacillogenous cases, caused by the tubercle bacillus, the Uro- 
bacillus liquefaciens. Bacillus coli communis, and the typhoid 
bacillus. 

(c) Coccogenous cases, caused by the gonococcus, staphylococcus, 
streptococcus, and various diplococci. 

Of all the micro-organisms mentioned, the Bacillus coli communis 
is the most frequent cause of cystitis (Melchior). 

The direct exciting causes of cystitis in children, as in the 
adult, are cold, catheterization, or calculi. It may follow urethritis, 
vulvitis, or may complicate the infectious diseases — scarlet fever, 
typhoid fever, and diphtheria. The changes in the bladder are, as 
in the adult, swelling and hyperemia of the mucous membrane. In 
chronic cases there are thickening of the rugse, ulcerations, hemor- 
rhages, and the formation of false membrane (diphtheria). 

Symptoms. — The symptoms are deep-seated pelvic pain, a desire 
to pass urine, and, frequently, pain in urination. There may be 
slight fever. The urine is passed in small quantities, is cloudy, and 
contains flocculi and shreds of mucus and muco-pus. There is 
sometimes a sediment of creamy consistency. The urine may con- 
tain blood and pieces of false membrane (diphtheria). In tuber- 
culous cases, there are tubercle bacilli in the urine. 

The cases may be acute, lasting only a week or two, or may be 
chronic, and last for months. In the variety caused by the coli 
bacteria (Escherich) the urine is acid. It may be acid in other 
acute forms. In the chronic tuberculous cases the urine may be 
alkaline and contain crystals of triple phosphates. The tendency 
in acute cases is toward recovery. Complications, such as pyelitis 
and peritonitis, may occur. 

Treatment. — If the symptoms are acute, the child is put to bed, 
and the bladder washed out with a solution of creolin. Salol, grain 
ij (0.12), is given three or four times daily. Urotropin, grain iij (0.18), 
is of great utility in the ammoniacal forms of cystitis. Alkaline 
waters (Vichy) are given freely and the bowels are kept open with 
alkaline salts. In convalescence an alkali, such as citrate of potas- 
sium, given in grains v (0.3) t. i. d., is beneficial. 

In chronic forms saccharin is sometimes the only drug that will 
give relief. Grains ij (0.12) t. i. d. may be administered to a child 
of six years with safety. 



CYSTITIS. 765 



Bacteriuria. 



This is a condition in which the urine assumes a very foetid odor, 
as of decomposition, becomes filled with bacteria, generally of the 
coli or the Staphylococcus albus group ; the urine is usually acid in 
reaction, though cases are recorded in which the reaction was alka- 
line or neutral. There are no evidences of cystitis or inflammation 
of the urogenital tract. 

Occurrence. — It occurs, as a rule, indelicate children. Most of 
the cases coming under my observation were suffering from various 
aflPections of the gastro-enteric tract. Female children are mostly 
affected. It occurs in children from the fifth to the thirteenth year 
of life. 

Symptoms. — Some cases set in with fever, headache, vomiting, 
and pain over the bladder. Other children complain of dysuria ; 
whereas in many cases the onset is insidious, and when consulted the 
physician encounters the following symptoms : If old enough to 
describe their symptoms, the little patients complain of slight head- 
ache, and there is a slight febrile reaction. The main symptoms are 
confined to the urine, which is passed frequently, with pain referred 
to the bladder. The urine is dark, has a musty or foul odor, and is 
acid in reaction as a rule. It contains no albumin, or only a trace ; 
no sugar ; and there are present no evidences of cystitis. There is 
no inflammation of the o^enitals. In most cases the Bacillus coli 
communis is found in pure culture ; in other cases, the Staphylo- 
coccus pyogenes albus is present. 

Pathogeny. — The manner in which the urine is infected in these 
cases is still a matter of discussion, though many are agreed that the 
affection may occur in the majority of cases by way of the gastro- 
intestinal tract, or in younger children by way of the urethra. 

Treatment. — The prognosis is good in most cases, inasmuch as 
recovery occurs in periods of from one to several weeks. 

The children should be kept quiet in bed. Yichy water and 
salol are administered internally ; the bladder is washed with a 3 per 
cent, solution of boric acid in severe cases, or \ per cent, solution of 
lysol. 

References of Authorities for Collateral Reading. 

Aht, J. A. : " Floating Kidneys in Children," Jour. Ainer. Med. Assoc, 1901. 
Baginsky, A. : " Ueber Pyelonephritis im Kindesalter," Deutsch. med. Wochen., 
1897. 

Barlow: " Beitrg. zur setiol. and Cystitis," Arch. f. Dermat, 1893. 
Bockenheimer : Die Kongenitale Cysteninere, Dissert., Wurz., 1897. 
Comby, J. : "Floating Kidney," Trans. British Med. Assoc, 1898. 

"Lithiese chez les Enfants," VI. Verhandl. gesell. Kinderheilk. 

Churchill, F. S. : " Cyclical Albuminuria," Trans. Araer. Ped. Soc, vol. xiii. 
Cahen-Brach : "Urogenital Blennorrhoea," IX. Verhandl. gesell. f. Kinder., 1891. 
Delafield, F. : " Bright's Disease," Amer. Jour. Med. Sciences, 1891. 



766 DISEASES OF THE KIDNEYS AND UROGENITAL TRACT. 

Escherich, T. : " Ueber Cystitis bei Kinder," Mitt, aus der Verein der Aerzle, 
Steiermark, No. 5, 1894. 

Fordyce : " Cases of Urinary Infection with Bact. Coli," Jour. Cutan. and Gen- 
Urin. Dis., 1893. 

Freemann, R. G. : " Nephritis in Influenza," Trans. Anier. Ped. Soc, vol. xii. 

Hartley, F. : '' Gonorrhoea! Rheumatism," New York Med. Jour., 1887. 

Heiman, H : " Vulvo-vaginitis," New York Med. Eec, 1895-1898. 

Heineke: Maligne Nierengeschwulzte in Kindersalter, Dissert., Miinchen, 1897. 

Hunner and Harris : Acute General Gonorrhoeal Infection, Bull., Johns Hop- 
kins Hospital, vol. viii., No. 135. 

Jacobi, A. : " Primary Sarcoma of the Kidney," etc.. Trans. Internat. Med. 
Cong., Copenhagen, 1884. 

" Floating Kidney " in Therapeutics of Infancy and Childhood. 

Koplik: ''Urogenital Blennorrhoea," Jour. Cutan, and Gen.-Urin. Dis., 1893. 

" Arthritis Complicating Vulvo-vaginitis," New Y'ork Med. Jour., 1890. 

Lewi, E.: "Sarcoma of the Kidney," Arch, of Ped., 1896. 

Melchior, 31.: Cystitis u. urininfection, Berlin, 1897. 

Horse, J. L. : " Renal Complications of Acute Enteric Origin," Trans. Amer. 
Ped. Soc, vol. xi. 

Pott : Jahrb. f. Kinderheilk., 1883. 

Rachford, B. L. : "Albuminuria as a Lithsemic Manifestation," Trans. Amer. 
Ped. Soc, vol. X, 

Sanger: Die Tripperansteckung beim weib, Leipzig, 1889. 

Senator : " Die Erkrank. der Nieren.," Nothnagel's Spec Path, und Therap., 
Bd. xix. 



SECTION XIII. 

DISEASES OF THE NERVOUS SYSTEM. 
METHODS OF DIAGNOSIS. 

Lumbar Puncture. 

Lumbar puncture was first practised by Quincke. It is to-day 
one of the most useful adjuncts to the methods of diagnosis in acute 
and chronic forms of cerebral and spinal disease. Its future useful- 
ness as a therapeutic measure is not clearly established, bat will 
probably lie in relieving symptoms due to pressure, and removing the 
excess of inflammatory exudate in the various forms of meningitis. 

The Normal Cerebrospinal Fluid. 

Normal cerebrospinal fluid is a clear colorless fluid having a 
slightly alkaline or neutral reaction. Its specific gravity varies from 
1007 to 1009. It contains from 0.05 to 0.1 per cent, of albumin 
(Quincke, Rieken, Pfaundler), and because of the presence of sugar 
has a slightly reducing action on copper. It does not coagulate spon- 
taneously. If centrifuged, a microscopic sediment of a few endo- 
thelial cells and leucocytes may be obtained. The cerebrospinal fluid 
is normally under a pressure of from 5 to 35 millimetres of mercury. 
The pressure in infants is lower than that in children. The causes 
of the variations of pressure and the nature of the conditions under 
which they occur have not as yet been determined. Respiration 
causes a deviation of fully 6 millimetres of mercury in the manom- 
eter column. 

Abnormal Conditions. — The cerebrospinal fluid will in patho- 
logical states vary in respect to specific gravity, composition, appear- 
ance, and in the amount of sediment contained. The pressure in the 
subarachnoid and cerebrospinal spaces will also vary in different 
forms of disease. 

The specific gravity in tuberculous meningitis varies from 1003 to 
1011 (Lenhartz), in cerebrospinal meningitis from 1005 to 1012 
(Pfaundler). 

The gross appearances of the fluid obtained by lumbar puncture 
may be changed by the admixture of blood. Blood may come from 
the puncture wound or may have been in the canal previous to 
puncture as a result of a hemorrhagic pachymeningitis or of some 
form of cerebrospinal meningitis, traumatism, or apoplexy with 

767 



768 DISEASES OF THE NERVOUS SYSTEM. 

rupture into the ventricles. The wounding of veins either in the 
tissues or in the cauda equina may cause the admixture of blood. 
The quantity of blood may be just sufficient to tinge the fluid or 
the blood may be almost pure. It is not possible to determine 
whether the admixture of blood is or is not the result of accidental 
puncture of a vessel unless, as in pachymeningitis or traumatism, 
light is thrown on the matter by the history of the case and the 
presence of blood on repeated puncture. The accidental admixture 
of blood is unfortunate, since it obscures the microscopical diagnosis. 
The hemorrhage into the spinal canal is never alarming or of serious 
import. 

Tuberculous meningitis changes the gross appearance of the fluid 
obtained by lumbar puncture. The fluid may be quite clear, excep- 
tionally cloudy, opalescent, or in rare cases purulent. As a rule, 
however, it is clear in the early stages of the disease and cloudy in 
the later period. If the test-tube is held in a strong light, there 
may be seen, in a clear or cloudy fluid, myriads of highly refracting 
particles resembling the motes in a sunbeam (Moser, Bernheim, 
Pfaundler). The appearance is quite characteristic. It was first 
explained by Lichtheim, as the result of spontaneous coagulation. 
If a test-tube of the fluid obtained by lumbar puncture is placed in 
the upright position in an ice-box, there is found after twenty-four 
hours, a fully formed cobweb-like, funnel-shaped coagulum, beginning 
a little below the surface of the fluid and extending downward, the 
broader part of the funnel being above. According to Pfaundler, 
this coagulum is of diagnostic import. I have relied on its appear- 
ance in fluid which was not contaminated with blood, and found it 
of great value. The formation of the coagulum begins after the fluid 
has stood for two hours, and is fully completed by the following day. 
It is usually found from eight to twelve days before death. 

Suppurative Meningitis. — In this form of meningitis, the fluid 
obtained by lumbar puncture is purulent, opalescent, grayish- white, 
grayish-yellow, or brownish (hemorrhagic). Exceptional cases give 
a clear fluid. There may be a spontaneous coagulum resembling 
that seen in tuberculous meningitis. 

Epidemic and Sporadic Cerebrospinal Meningitis. — In the early 
stage of this disease, the fluid may be quite clear with suspended 
microscopic sediment. It may also be cloudy or thick, creamy or 
bloody. It may at first be clear, and later in the disease become 
purulent (Councilman). 

Chronic Hydrocephalus. — This gives a clear fluid with no sus- 
pended particles visible to the eye, although microscopially there may 
be leucocytes. Pfaundler in one of his cases obtained a fluid which 
was cloudy because of the admixture of leucocytes. 

Tumor of the brain gives a clear fluid. I have had a case of 
this kind. 



>> 

a 



X 
I— I 

X 

X 

w 

< 




S (D 



1 ^ 

(D CC 





+j 

0) 

a 




THE OPERATION OF LUMBAR PUNCTURE. 769 

Sediment. — This feature will be fully discussed under the sections 
devoted to Tuberculous Meningitis and Cerebrospinal Meningitis. 

The pressure under which the cerebrospinal fluid is retained in 
the subarachnoid space and in the spinal canal is increased in the 
various forms of meningitis. This is especially true of tuberculous 
meningitis, in which the pressure may reach 110 m.m. of mer- 
cury. In this disease the pressure increases from the initial period 
to that of pressure symptoms, and diminishes toward the close of 
the disease — the stage of paralysis. Ventricular involvement gives 
the highest pressure figures. The following figures are taken from 
Pfaundler^s tables : 

First stage 48 m.m. of mercury. 

Stage of pressure 52 m.m. " " 

Stage of paralysis 24 m.m, " " 

In suppurative meningitis, the pressure varies from 10 to 37 m.m. 
of mercury ; in cerebrospinal meningitis, from 24 to 50 m.m. ; in 
hydrocephalus, from 6 to 60 m.m. ; in tumor of the brain, from 3 
to 52 m.m. (Quincke, Slawyk, Pfaundler). 

The presence of an increased amount of albumin in pathological 
states has been noted by Wentworth, Quincke, and Pfaundler. In 
tuberculous meningitis it may reach 0.3 per cent. ; in purulent menin- 
gitis, 0.6 per cent. 

The Operation of Lumbar Puncture. 

The instrument consists of a trocar and canula such as is em- 
ployed in tapping cavities. The best form of instrument is that 
devised by Quincke (Fig. 166). The canula should be at least one 
millimetre in diameter. It is not necessary to use a manometer. 
In infants the tenseness of the fontanelle is a rough guide in esti- 
mating the pressure in the subarachnoid space. 

Place of Puncture. — The puncture is made in the space between 
the third and fourth or the fourth and fifth lumbar vertebrae. This 
point is obtained by palpating the crests of the ilium ; an imaginary 
tangent to these crests strikes the fourth space. The space above 
this imaginary line will, as a rule, be found to be the third space. 
Puncturing the canal in the space between the sacrum and coccyx 
or in the lower sacral space offers no advantages either anatomically 
or from a diagnostic standpoint. 

Method. — Local anaesthesia only is necessary. The back of 
the patient is carefully scrubbed with green soap, then washed 
with alcohol and ether, and finally with sublimate. The patient 
is laid on either side according to the convenience of the operator. 
The spine is curved so that the spinous processes may be distinctly 
seen and palpated (Plate XXIX.). No considerable pressure should 
49 



770 



DISEASES OF THE NERVOUS SYSTEM. 



Fig. ler. 



be brought to bear on the neck, since in cerebrospinal meningitis 
or in the basilar form of meningitis in which there is opisthotonos, 
serious injury to the neck may be caused. The spine is curved 
from the shoulders and pelvis. The needle, having been previously 
boiled, is introduced in the median line between the spinous 
processes and is directed upward (Plate XXX.). When it is in 
the canal, it is perceived that there is a lack of 
resistance, and that the point of the instrument 
is free. The canula is withdrawn and the first 
drops caught in a sterilized test-tube. A second 
test-tube is substituted for the first after a few 
drops of bloody fluid have been allowed to flow 
out, and from 10 to 50 c.c. of fluid are with- 
drawn, the amount varying with the pressure. 
If it flows drop by drop, 20 c.c. are suflicient 
for diagnostic purposes and also to relieve the 
pressure. If there is opisthotonos and the fluid 
does not flow well at first, cautious straighten- 
ing of the neck will facilitate the outflow. In 
infants the fontanelle is a good guide in gaug- 
ing the pressure. As soon as a few cubic centi- 
metres of the fluid have been withdrawn, the 
fontanelle will be felt to be considerably flattened 
and relaxed or even depressed. Heubner has 
withdrawn 100 c.c, but the removal of such 
large quantities is unnecessary and may be fol- 
lowed by hyperpyrexia and collapse. I rarely 
withdraw more than 20 c.c. If there is a dry 
tap, the canula should be withdrawn and a 
second attempt made on the following day. A dry tap may be 
caused by a fibrin clot or by the falling of the cauda equina in front 
of the opening of the canula. The fluid may be viscid and refuse 
to flow. In that case the fluid should not be aspirated with a 
syringe, since in the experimental laboratory this method has been 
proved to be hazardous. If carried out as above directed, I have 
never seen any ill results from the operation of lumbar puncture. 
After puncture, the canula is rapidly withdrawn and the wound 
dressed with iodoformized gauze. 

Indications for Lumbar Puncture. — Lumbar puncture is per- 
formed in the various forms of meningitis for diagnostic purposes, 
to determine the character of the fluid. It is not always an easy 
task to decide whether it should be resorted to. The decision 
is especially difficult in private practice, where the procedure is 
regarded with dread. Any marked disease of the lungs should 
first be excluded. In many cases of pneumonia the cerebral symp- 
toms are marked. Only very marked symptoms of cerebral press- 




The Quincke needle for 
lumbar puncture. 



X 

X 
X 

w 

< 




COIiVULSIONS IN INFANCY AND CHILDHOOD. 771 

ure and the suspicion of pnenmococcus meningitis should cause the 
physician to resort to puncture in order to fix the diagnosis. It 
is best not to perform it while the lesion in the lung is markedly 
active. Cases of tumor of the brain should not be subjected to 
puncture. 

Indefinite cerebral symptoms, such as headache, restlessness, and 
convulsions of a general character, are not indications for puncture. 
I have seen cases of meningitis of the cerebrospinal type which gave 
few symptoms of disease, there being indefinite sopor, general mus- 
cular weakness with delayed reflex at the knee and marked emacia- 
tion, but no marked rigidity of the neck. 

In doubtful cases I refrain from puncture. Cases with meningeal 
symptoms, in which there is a history of a blow, are proper subjects 
for puncture, since it is necessary to differentiate between menin- 
gitis, and abscess of the brain. In the various forms of purulent 
meningitis, symptoms of pressure such as convulsions, and signs of 
suppuration such as chills, are indications for puncture. After the 
first puncture is made and the diagnosis fixed, I do not in tuberculous 
meningitis repeat the operation. 

The indications for puncture in other diseases such as hydroceph- 
alus will be discussed under the headings of the various affections. 



CONVULSIONS IN INFANCY AND CHILDHOOD. 

Eclampsia Infantum. 

Convulsions are a series of violent clonic contractions of a num- 
ber of muscles, or of the muscles supplying one limb. There is 
always more or less of a tonic spasm at first. The convulsions are 
paroxysmal and accompanied by a loss of consciousness. In this 
section the acute convulsions of infancy and childhood are especially 
considered, and will be differentiated from certain spasmodic affec- 
tions, such as laryngismus, tetanus, and epilepsy, which are ac- 
companied by spasms, though classed by some as forms of con- 
vulsions. 

Classification. — Convulsions of infancy may be classified as 
those which are primary or idiopathic, and those which are secondary, 
reflex, or symptomatic. In the first rubric are included the convul- 
sions which occur spontaneously, or after some sensory irritation, 
very often of an obscure origin, such as epileptic, hystero-epileptic 
seizures, and tic. AYith increasing knowledge this class is gradually 
becoming more and more limited. 

In the second class the symptomatic or reflex convulsions are 
included : (a) the cases which follow abnormal conditions of the 
circulation in the brain, such as anaemia or hypersemia ; (b) convul- 
sions which occur at the outset of infectious diseases ; (c) convul- 



772 DISEASES OF THE NERVOUS SYSTEM. 

sions which are caused by disturbance of metabolism, and which 
occur at the outset or in the course of certain diseases in which tox- 
ins are thrown into the blood ; (d) those which follow some per- 
ipheral irritation, such as occurs in a reflex manner in wounds, 
burns, etc., or directly reflex, as in meningitis, tumors of the brain, 
hydrocephalus, brain compression, poisons circulating in the blood 
(lead). 

Occurrence. — The acute convulsions of infancy and childhood 
are symptomatic, and occur chiefly during the first half year of life. 
Fully four-fifths of the cases occur before the end of the second year 
of life. They are uncommon after this period ; but a child who 
has had convulsions of the symptomatic type in infancy is likely 
to have a recurrence of the convulsions up to the seventh year of 
childhood. 

Etiology. — The occurrence of convulsions necessitates not only 
the presence of an exciting agent or irritating substance, but there 
must exist a certain constitutional disposition or predisposition to 
convulsions, which may be hereditary. Soltmann has shown that in 
the newborn animal irritability of the motor nerves is almost nil, 
and that of the sensory nerves much below what is attained in later 
life. In the newborn, also, there is an absence of reflex inhibition, 
and the brain lacks volition ; in other words, there is an absence of 
the psycho-motor centres. The inhibitory centres do not develop in 
parallel lines with the peripheral irritability of the sensory nerves. 
Reflex irritability is very much diminished at the outset, but increases 
later, becoming, at a certain period of infancy, above what is found 
in the adult. The musculature of the infant, on account of the 
instability of the nervous centres, can be thrown into tetanic con- 
traction by the least irritation. This period of increased reflex irri- 
tability of the nervous centres has been placed by Soltmann at from 
the fifth to the eleventh month of infancy, thus corresponding with 
what is found in the human subject clinically. 

Although the theories of Soltmann are not wholly endorsed by 
other observers, it remains true that in infancy the inhibitory centres 
are not fully active, that the psychomotor centres are absent, and 
that this is a period of increased reflex irritability of the peripheral 
nerves. In a causal sense, not only does this increased reflex irri- 
tability predispose to acute convulsions in infancy and childhood, but 
with it there is a hsematogenous toxic element especially active at 
this period of life. 

In infancy we have also the hereditary predisposition to neuroses, 
and tendencies derived from neurasthenic, alcoholic, syphilitic, and 
tuberculous parents. 

It seems, therefore, that causal agents of acute convulsions in 
infancy and childhood are principally periodical toxins, such as are 
present in the circulation (hsematogenous) at the outset of infectious 



CONVULSIONS IN INFANCY AND CHILDHOOD. 773 

diseases, as acute amygdalitis, exanthemata, typhoid fever, malaria, 
influenza, pertussis, mumps — all of which may be ushered in with a 
convulsion. 

The explosion appears to be caused by the initial effect of the 
toxins and temperature on the ganglion-cell. Convulsions sometimes 
takes the place of the initial chill in pneumonia and malarial fever. 

The disturbances of metabolism which may cause toxins to be 
thrown into the circulation occur in connection with gastro-enteric 
disease of any kind or with indiscretions in diet. Children who eat 
an excessive quantity of meat are particularly subject to these seizures. 
In addition to the above exciting agents we have mentioned also 
disturbances of the circulation which may cause convulsions, and 
these are found in connection with pertussis, bronchitis, and heart 
disease. In these affections there is an accumulation of carbonic 
acid gas in the circulation, which is the exciting agent of the 
intitial explosion ; and, finally, we have as causes of convulsions 
the direct effect of mineral poisons, such as lead, circulating in the 
blood. 

Convulsions, according to some authors, may be caused by the 
presence of alcohol in the mother's milk. This is a very question- 
able cause of convulsions. Rarely, convulsions may be caused by 
reflex irritation of a foreign body in the stomach, or by overdistention 
of the stomach during stomach-washing, an instance of which the 
author has seen ; by burns, wounds, effects of cold, incarcera- 
tion of a hernia. Retention of urine may, by reflex peripheral 
irritation, cause convulsions. The toxic form of convulsions occurs 
in uraemia. 

Dentition is frequently mentioned among the causes of convul- 
sions. Since dentition in a normal infant is devoid of symptoms, 
it is straining a theory to ascribe convulsions to irritation of the 
trigeminal branches. The acceptation of this dentition theory might 
lead one to overlook some serious condition, of which the first indi- 
cation is an eclamptic seizure. 

Under the heading of circulatory disturbances might further be 
mentioned an acute cerebral anaemia, caused by severe hemorrhage, 
which may give rise to a convulsion. Such convulsions are hardly 
included under the conception of infantile convulsions of the acute 

type. 

The pathogeny of convulsions in infancy and childhood is the 
same as in the adult. The explosions are due to irritation of the 
centres in the ponto-bulbar junction, or in the area of Rolando 
(Hughlings Jackson). The starting-point of every convulsion is a 
ganglion-cell. It is not known whether the inherited neurotic ten- 
dencies already mentioned are powerful factors during infancy, or 
Avhether alcoholism or epilepsy in the family are active in causing 
convulsions of the purely acute type in infancy. Rachitic children, 



774 DISEASES OF THE NERVOUS SYSTEM. 

however, according to Kassowitz and Elsasser, are peculiarly subject 
to convulsions, because the cranial bones are the seat of hypersemia 
and softening. The motor areas adjacent to these points of hyper- 
semia and softening are supposed to be in a state of constant irrita- 
bility. 

Kussmaul and Tenner have demonstrated that there is an acute 
anaemia of the brain during convulsions. On the other hand, it often 
happens that the convulsion is the cause of the bursting of a cerebral 
vessel. In such cases the signs of cerebral surface hemorrhage are 
present at autopsy. In other cases, although death has occurred 
during a convulsion, nothing is found post mortem but an oedema 
of the brain substance, of doubtful origin. 

Symptoms. — The majority of convulsive seizures in infants and 
children are single. In certain cases the convulsions are repeated 
and extend over a prolonged period. The latter are not cases of 
simple acute infantile convulsions. The symptoms of acute eclamp- 
sia are sometimes so very slight as to be scarcely noticeable. A very 
observant mother will see a slight twitching of the lips and eyelids, 
a momentary turning of the eye and cessation of breathing, or a 
momentary spasm of the whole trunk. The expression " internal 
convulsion,'' so frequently heard, evidently denotes these slight 
eclamptic seizures. The genuine convulsion comes on without pre- 
monitory symptoms. There is a momentary spasm of the body, the 
head turns to one side and upward, and there is a corresponding 
upward direction of the eye. Then follow a series of clonic 
spasms involving the upper and lower extremities, and lasting for 
some time. 

The hands are clenched, the forearms flexed, the body rigid, 
the lower extremities extended, the head thrown back. This tonic, 
momentary spasm is followed by a clonic spasm, beginning in the 
muscles of the face and involving those of the trunk and extremities. 
The teeth are set, the tongue is protruded and may be bitten. There 
are cyanosis and frothing at the mouth. The respirations are short 
and hissing, the pulse is imperceptible, and at the outset of the 
convulsion the heart becomes slow and irregular. A cold perspira- 
tion bathes the surface. The convulsive seizure may be momentary, 
may last a few minutes to a quarter of an hour, or one spasm may 
be followed rapidly by others extending over the same period of time. 
Toward the termination of the convulsive spasm the clonic contrac- 
tions become less frequent ; the child passes into a sleep or coma. 
In some cases the clonic spasms may be limited to one side of the 
body. 

The child may be in a state of eclampsia for an hour, after which 
it may pass into the comatose state. The coma may be momen- 
tary or may merge into a sleep of variable duration. The end 
of the convulsive spasm is signalized by muscular clonic spasms 



CONVULSIONS IN INFANCY AND CHILDHOOD. 775 

decreasing in severity, until finally a long-drawn inspiration ends 
the attack. 

Diagnosis. — It is very important to be able to distinguish be- 
tween the various forms of convulsive seizures. Those occurring 
immediately after or within a few hours or days of birth have a 
different etiology from those just described. They may be caused 
by cerebral hemorrhage, and there will be symptoms after the con- 
vulsions, such as palsies, contracture, difficulty in deglutition, and 
prolonged coma. In these cases the convulsions are repeated. Ate- 
lectasis of the congenital variety may cause convulsions. The 
patients have slight or marked cyanosis, and, in the intervals, increase 
of respirations and signs of bronchitis and collapse of the lung. 

Tumor and abscess of the brain, and meningitis, both cerebro- 
spinal and tuberculous, may be ushered in by convulsions. In tumor, 
the convulsions are limited to the area in which the tumor or abscess 
is localized. In forms of meningitis, there will be the symptoms of 
that disease. Drugs and poisons may give rise to convulsions. The 
history of such cases will be of service. Cases of tetany and tetanus 
have convulsions in the course of the disease. In tetany there may 
be several convulsions in the course of twenty -four hours. Tonic 
spasm is the chief feature of the convulsion in tetany and tetanus. 
The clonic form distinguishes acute convulsions. In tetanus there is 
slowly increasing opisthotonos. In tetany the body may be lax in 
the interval, but there are rare cases of tetany which resemble 
tetanus in that there is rigidity in the intervals between the 
spasms. In tetany the extremities have a characteristic position. 
In some cases of simple acute infantile convulsions, an increased 
irritability of the nerves and muscles to mechanical stimulus re- 
mains for days after the paroxysms. The Chvostek and Trous- 
seau phenomena are found. Some authors have regarded these 
cases as cases of latent tetany. The diagnosis of the various epi- 
leptiform seizures will be considered in the section devoted to that 
subject. 

The prognosis of acute infantile convulsions is generally good, 
but since death has occurred in these seizures, as well as cerebral 
hemorrhage, caution should always be exercised in predicting the 
immediate outcome. The patient having been once tided over the 
initial paroxysm, it may be confidently expected that it will not be 
repeated. In the presence of fever, it cannot be predicted what 
affection may follow the seizure. Primary seizures should not be 
regarded as forerunners of epilepsy. Many infants and children 
affected with convulsive seizures pass through later life without 
any sign of that disease. 

Treatment. — The seizure is frequently over before the physician 
arrives. If such is the case and the infant is in the stage of stupor, 
it should not be disturbed unless there is high fever or a history 



776 DISEASES OF THE NERVOUS SYSTEM. 

of the patient's having eaten some irritating substance. It often 
happens that the paroxysm supervenes in the presence of the physi- 
cian. The patient is placed on a bed, the clothes loosened, and 
a small object, such as the handle of a tooth-brush, placed between 
the teeth to save the tongue from injury. Nothing further is needed. 
The paroxysm is as a rule over in three minutes at most. If it 
persists or is immediately succeeded by another, the patient is 
placed in a warm bath, after which a few drops of chloroform are 
administered by inhalation to control the convulsions. A high 
rectal enema of the temperature of 110° F. (43.3° C.) is at once 
administered. I have in some cases continued the administration of 
chloroform for fully an hour. Caution should be exercised in its 
administration. If, after the seizure, the temperature is high, it is 
treated as indicated in the section on Infectious Diseases. Unless 
there is some contraindication, a full dose of calomel is administered 
as a routine procedure even if an enema has been resorted to. 
Should the child be restless, it is well after the convulsion to admin- 
ister a dose of bromide of potassium in combination with chloral, 
either by mouth or rectum. In repeated convulsions the adminis- 
tration of these drugs during the seizures is of inestimable value. 

For several years past I have used the postural treatment in 
acute convulsive seizures. The patient is placed with the head 
low, the buttocks raised, and the clothes loosened. I think the 
paroxysms have been shortened by this treatment. It was suggested 
by the theory that cerebral anaemia is the cause of the initial 
paroxysm. I have carried out this postural treatment without any 
ill after effects, such as hemorrhage. In a large number of cases of 
repeated convulsions, the postural treatment should be supplemented 
by chloroform inhalations. 



HYSTERIA. 

Hysteria is a morbid state of the nervous system in which the 
primary derangement is in the higher cerebral centres. The lower 
centres of the brain, the spinal cord, and the sympathetic system may 
be secondarily disordered (Gowers). It is not a true disorder of 
childhood. Sixteen per cent, of all the cases of hysteria occur in 
youth (Steiner). 

Etiology. — Hysteria is rarer in children than in adults, is more 
frequent in the female sex, and is more often seen in boys than in men. 
According to Briquet and Landouzy, 8 per cent, of all the cases occur 
in the first decade of life, and 50 per cent, in the second. The cases 
of the first decade, according to Barlow, generally develop at the age 
of six years. Cases are occasionally seen in patients of the age of 
three years. Heredity plays an important etiological role. Moral 



HYSTERIA. 777 

and mental influences predispose to development of the condition. 
Children of emotional antecedents are apt to be subject to the disease. 
Sexual disturbances or excesses (as masturbation in boys) are exciting 
causes. Abnormalities of the sexual organs, phimosis, and hypos- 
padias, are apt to excite masturbation and resultant hysteria. In 
some subjects, any acute disease, such as pneumonia or typhoid 
fever, will develop latent tendencies to hysteria. Diphtheritic paral- 
ysis may eventuate in hysterical palsy (Growers). 

Symptoms. — The disease shows many variations and most 
diverse symptoms. The symptoms may be divided into psychic, 
motor, and sensory manifestations ; or into the convulsive and non- 
convulsive forms of hysteria. 

Psyschic or Mental Hysteria (Non-convulsive). — In most cases 
of this class, the patients suffer from some mental strain. The 
attack begins with a paroxysm of crying or of laughing. The child 
then passes into a violent condition, striking at persons and tearing 
the clothes from its body. I saw a case of this kind in a boy eight 
years of age. He was very bright at school, but shunned the 
companionship of other boys. He masturbated. At times he was 
of a very loving disposition, at other times would refuse to do 
as he was told. The rebellion would terminate in a paroxysm of 
crying, followed by one of shrieking. The boy would tear his 
clothes and then calm down quite exhausted. Girls after undergoing 
some mental strain, such as is incident to a school examination, 
become irritable, morose, and suffer from insomnia. They have laugh- 
ing and crying spells and refuse nourishment. After a period of 
these symptoms they either recover or pass into a state resembling 
acute mania. Such children are nervous and are born of neurotic 
parents. 

Hystero-epilepsy, catalepsy, or trance symptoms may manifest 
themselves. These cases are rare in children, but Sachs and Steiner 
have seen them in children of mentally degenerate families. 

Insanity, alcoholism, and chorea in the family predispose to the 
development of hysteria. These cases must be differentiated from 
those of true epilepsy. 

Motor Manifestations (Convulsive Forms). — These occur in the 
form of hystero-epileptic attacks. After some mental excitement, 
a paroxysm beginning with a shriek will supervene, the sounds 
simulating a bark or a snapping sound. Contortions then supervene 
and the back is arched, as shown in Richer's drawings. During the 
attack, which may last for several minutes, there may be no evidence 
of consciousness. There may be a number of such attacks in the 
course of twenty-four hours. The patient may suddenly fall down and 
have contortions, and the attack may terminate in a crying spell. 
The patients sometimes tear their clothing and become violent. 
These convulsions are differentiated from true epilepsy in that there 



778 DISEASES OF THE NERVOUS SYSTEM. 

is no aura ; they are preceded by emotional excitement. The onset 
is gradual and the patients emit noises of various kinds during the 
attack. The pupils are normal. There are ecstasy, extravagant 
movements, and tonic rigidity. The vesical and rectal reflexes are 
normal. The patients do not bite the tongue, and rarely injure 
themselves ; the loss of consciousness is temporary or imperfect. 
There are in hysteria irregular twitchings of the extremities and a 
repetition of one specific movement, such as retraction of the head. 
The spell or paroxysm ends in a crying or laughing fit, or the 
patients become melancholic. 

Among the manifestations of hysteria in children is the so- 
called hysterical stricture of the oesophagus, or globus hystericus. 
There may be spasm of the bladder, hiccough, and loss of voice. 
The latter is common among young girls. I have seen the 
children recover their voice under hypnotic suggestion. Hysterical 
children may, even at the early age of five years, pass under hypnotic 
suggestion, into a trance-like state. Whether diarrhoea can be caused 
by hysteria is in my opinion doubtful. I have seen true toxic 
diarrhoea in neurotic children diagnosed as nervous or hysterical. 
One case occurred in a boy of six years. Some young girls have 
attacks in which all varieties of poses are assumed in the nude state. 
I have seen such a case in a highly intelligent girl of nine years. 
During the morning bath, the child had a desire to assume the most 
grotesque poses. 

The so-called epidemics of chorea are now known to be simple 
hysteria. Among these are to be classed the school epidemics and 
the dancing mania of the Middle Ages. 

There may not only be convulsive movements, but also absolute 
paralysis of single muscles or of a group of muscles. Hysterical 
paralyses as a rule follow no anatomical distribution. They are dis- 
tinguished from true palsies by the lack of change in the electrical 
reactions and in the condition of the deep reflexes. The sphincters 
are normal. Paralyses, such as those due to neuritis or poliomyelitis, 
may supervene in a hysterical subject. 

The disturbances of sensation include hypersesthesias and anaes- 
thesias. These do not differ essentially from similar conditions in 
the adult subject. There may be hypersesthesia in the region of the 
ovary, or in the skin over the vertebral column. Areas of irritation 
may cause paroxysms. There are hysterogenic zones which are not 
hypersesthetic (Sachs). Anaesthesia, partial or general, is more 
frequent. There may be absolute anaesthesia to all sensation. There 
may be blindness in one eye or hemianopsia, deafness, or loss of 
taste or of smell. Vision may be affected as above described, or 
there may be photophobia and diminution of visual perception ; the 
retina may be insensible to light, and there may be limitation of the 
field of vision or temporary bilateral loss of sight. 



TETANY. 779 

There are in children cases of anorexia which supervene with 
vomiting after some nervous strain. I have seen this occur in chil- 
dren who were beginning some course of study. In one case it came 
on in the morning just before the child started for school. With 
suspension of school duties, the vomiting ceased. The so-called phan- 
tom abdominal tumor seen in rare instances among children may be 
traced to a hysterical cause. In very young girls I have frequently 
seen forms of palpitation with cardiac anguish which seemed to be 
hysterical. Steiner describes these forms of tachycardia. In these 
cases there is not only absence of cardiac lesion and signs of Base- 
dow's disease, but spinal hypersesthesia may be elicited. 

Diagnosis. — Sensitiveness to pressure over the vertebral column 
is one of the most frequent stigmata of infantile hysteria (Steiner). 
Epigastric tenderness is less frequent than among adults. Hyper- 
sesthesia is less marked in childhood than later in life, but is more 
common than anaesthesia. Jolly says that deep analgesia is rare. 
Of especial interest in its relation to diagnosis is the fact, that ocular 
symptoms, such as diplopia, may be present morning and evening. 
Paralysis may appear and disappear. There are forms in which 
there may be tachycardia or bradycardia, but during excitement the 
rhythm of the heart may be normal. Cases have been described in 
which the headaches, ptosis, and facial palsies simulate the symp- 
toms of tuberculous meningitis. Study alone will clear up such 
obscure cases. 

Duration and Course. — The symptoms of hysteria are not neces- 
sarily permanent, but are likely to recur after excitement or nervous 
strain of any kind. 

The treatment of hysteria in children is based on the same gen- 
eral principles as in the adult. The child is, if possible, removed 
from exciting surroundings. Studies are regulated and bad habits, 
such as masturbation, are, if possible, corrected. The effect of good 
food and outdoor life is marked. Hydrotherapy and massage achieve 
their greatest triumph in this affection. 



TETANY. 

( Tetanilla ; Arthrogryposis. ) 

Tetany is an intermittent or persistent, more or less painful, tonic 
spasm of groups of muscles of the upper and lower extremities. 

Forms and Frequency. — John Clark in 1815 described this 
disease in children. Trousseau, Baginsky, Chvostek, Erb, Escherich, 
and Ganghofner have completed its symptomatology. In children 
it is most common from the fourth to the twentieth month. There 
are two distinct forms. In the first, the contractures are intermit- 
tent, and come on at intervals, the patients being free from muscular 



780 DISEASES OF THE NERVOUS SYSTEM. 

spasm in the intervals. The second form, now accepted by the ma- 
jority of writers as the same aflFection as the former, is that in wliich 
the contractm'es are persistent. 

The etiology of this affection is still very obscure. It occurs 
most frequently in the winter and early spring. In my experience 
in an ambulatory clinic, it was customary to see these cases appear in 
groups in the early spring months. The affection is seen nnder the 
most diverse conditions. I'ully 63 per cent, of the cases are rachitic 
(Fischl). The percentage of rachitis must, of course, vary in differ- 
ent countries, but the cases coming under my notice have been chiefly 
of that character. The condition is not, as is frequently supposed, a 
rare one. I have regularly seen a number of these cases yearly. 
Many cases of tetany are not recognized as such by the physician. 
Cold, entozoa, infections of the gut, chronic intestinal disturbances 
of all kinds, rachitis, an enlarged thymus (Escherich), have all in 
turn been regarded as etiological factors. On the other hand, the 
general trend of opinion is to attribute the affection to a toxaemia 
probably originating in the gut and expending itself on the peripheral 
motor nerves. Fully 73 per cent, of Fischl's cases had shown in- 
testinal disturbances. The fact that the condition occurs in early 
infancy and in some respects resembles a normal state, to be de- 
scribed later, will account for its being frequently overlooked by the 
physician. 

Morbid Anatomy. — No definite account of the changes in the 
nervous system or elsewhere has as yet been given. Langhans has 
described a peri-arteritis and phlebitis in the white commissure and 
cervical portion of the cord. Gowers, without any positive data, 
assumes that there are some changes in the motor cells of the cord 
which cause the increased irritability of the peripheral motor nerves. 
Fischl in a recent article has published the post-mortem changes 
in his fatal cases. He makes, however, no comment on them. He 
found hydrocephalus interna and externa, oedema of the brain and 
meninges, tuberculosis of the brain, hemorrhagic infiltration of the 
cerebellum and meninges, chronic intestinal catarrh, and broncho- 
pneumonia. The affection occurs under the most diverse conditions. 

The symptoms consist of muscular contractures and phenomena 
connected with the peripheral motor nerves, which are known as 
Trousseau's phenomenon, Chvostek's facial symptom, and Erb's signs 
of increased electrical excitability of nerve and muscle. 

Muscular Contractures. — These come on without any premonitory 
symptoms. The infant or child may have been in good health, or 
may have been suffering from intestinal disturbance. There are 
two distinct forms of contracture in infants, in one of which the 
hands and arms take the position assumed in driving horses (Plate 
XXXI.). The arms are pressed against the thorax, the forearms flexed 
on the arms, and the fingers tightly flexed over the thumb into the 



PLATE XXXI. 




Tetany. Infant nine months of age. Shows the driviiig 
position of the fingers, hands, and arms, overextension of 
the feet and flexion of the toes. 



TETANY. 



781 



palm of the hands. The hand itself is strongly flexed on the fore- 
arm. The lower extremities may be addncted toward the median line, 
the thighs flexed on the abdomen, and the legs on the thighs. The 
feet are as a rule extended in the equinus position and the toes over- 
flexed on the plantar aspect of the foot, the whole foot being slightly 
curved inward. After the contractures have lasted some time, there 
is oedema of the tissues over the dorsum of the foot. In the 



Fig. 167. 




Tetany. Extension of the fingers, flexion of the arms, flexion of the toes. Child, eighteen 

months of age. 

second set of cases the fingers are overextended, as shown in Fig. 
167. The arms and lower extremities also take the position 
of flexion. These contractures are painful ; the patient cries as if 
in great pain when an attempt is made to straighten the flngers or 
extremities. There may be a temperature of two or three degrees. 
The contractnres may diminish, and there may be an interval in 
which the only symptoms are such as may be attributed to the 
increased mechanical and electrical irritability of the peripheral 



782 DISEASES OF THE NERVOUS SYSTEM. 

nerves. There may also be eclampsia. The eclamptic attacks are 
very dangerous. I have lost 2 cases in snch seizures. Other muscles, 
such as the abdominal or thoracic, may be the seat of contracture. 
In the latter case there may be cyanosis. 

I have seen cases in which all the muscles of the body were 
involved very much as in tetanic conditions. In one case there were 
stiffness of the muscles of the neck and loss of consciousness. 
Trismus is rare, and certainly does not occur at the outset, as in 
tetanus. The muscles of the face may be subject to contracture. 
The brow is wrinkled, and the face has an anxious expression. If 
the muscles over the zygoma are tapped, there is an instantaneous 
contracture or spasm of the orbicularis pali)ebrarum. In some cases, 
if the muscles of the face or the forehead are tapped, there is an 
instantaneous contracture of the muscles of the face, and some- 
times of other muscles of the body. This is called the facial 
phenomenon of Chvostek. If the nerves and arteries at the bend 
of the elbow are compressed, the characteristic tetany position is 
produced in the muscles of the hand and fingers. This phenomenon 
was first noticed by Trousseau, and bears his name. Erb established 
the fact that there is increased irritability of nerve and muscle tc 
the faradic and galvanic current. If the muscles or nerves elsewhere 
in the body are tapped, or if pressure is brought to bear at the point 
of exit of the nerve-trunks, there is an excessive irritability to this 
mechanical stimulus. The knee reflex is increased. 

Duration. — The disease may last a few hours, days, or weeks. 
In many cases the contractures disappear for a time, leaving the 
patient perfectly free from symptoms. They may return in all their 
original severity. The attacks leave the peripheral nerves in a con- 
dition of increased excitability. In such cases both the Chvostek 
and Trousseau plienomena may be present. 

The diagnosis of fully developed tetany is based on the presence 
of muscular contractures, of increased mechanical irritability of the 
peripheral nerves (as evinced in Chvostek's symptom), and the pres- 
ence of Trousseau's phenomenon. There are cases of tetany in which 
the facial symptoms are lacking. On the other hand, I have, in 
cases in which there was laryngospasm without contractures, obtained 
both the facial and Trousseau phenomena. 

The Relationship of Laryngospasm to Tetany. — Escherich, his 
pupil Loos, and also Ganghofner, have recently called attention to 
the fact that laryngosjmsm is present in a certain number of cases 
of tetany. They also fonnd that cases of laryngospasm which did 
not present contractures, did show the facial })hen()menon of Chvostek 
and the Trousseau symptom. They concluded that laryngospasm 
was a manifestation of tetany, whether the muscle contractures were 
present in the extremities or not. Their observations have been 
amply confirmed, but not all observers are as yet willing to accept 



CATALEPSY. 783 

laryngospasm without contractures of the muscles of the extremities 
as true tetany. The views of Kassowitz and Hochsinger are at 
variance with those of Escherich„ They consider rachitis the funda- 
mental cause of laryngospasm, if not of tetany. 

The term latent tetany has been applied to those cases which show 
no muscular contractures or laryngospasm, but in which the facial 
Trousseau or Erb phenonemon may be elicited, or in which the 
mechanical, and especially the electrical, contractibility of muscle and 
nerve are increased. 

Prognosis and Mortality. — The prognosis in the sporadic cases 
is very good. Parents should be cautioned in regard to the excita- 
bility of the patient and the possibility of eclampsia, with its fatal 
consequences. I have lost 2 cases in convulsions. The persistent 
cases may be complicated with other affections, such as tuberculous 
meningitis. If such is the case, the outcome is, as in the primary 
disease, fatal. Epidemics in hospitals for children present unfavor- 
able features; Escherich lost 37 per cent, of his cases. 

Treatment. — The bowels should first be evacuated. Calomel is 
given in grain J (0.03) doses two or three times daily. If there is 
any disturbance of the gut, the patient is given a high enema once a 
day. Milk is suspended until the movements take on a more favor- 
able appearance. The infant is kept under the influence of the 
mixed bromides of potassium, sodium, and ammonia. If there is 
eclampsia or increased irritability, a warm bath is given at least once 
a day. The patient is kept quiet and not disturbed mucho Nc 
attempt to straighten the limbs should be made, since it causes pain. 



CATALEPSY. 

Epstein has recently described a condition in children closely 
resembling a similar affection in the adult. He has described it as 
catalepsy occurring in infants poorly nourished and rachitic. The 
ages of his cases ranged from eighteen months to three and one- 
half years. Epstein believes there is a disturbance of the psy- 
chomotor functions. The phenomenon was observed by him chiefly 
in the lower extremities. Either extremity on being lifted into the 
air would stay there for a length of time in any position of flexion 
or extension in which it was placed. This phenomenon was not pres- 
ent during sleep, nor was it accompanied by any muscular rigidity 
or increase of mechanical or electrical irritability of the peripheral 
nerves. I have met a marked case of catalepsy following an attack 
of typhoid fever in a boy of four years. The hands, arms, and lower 
extremities would remain for long periods of time in the position in 
which they were placed. The boy would sit for long periods staring 
ahead, without winking the eyes. 



784 DISEASES OF THE NERVOUS SYSTEM. 

MYOTONIA. 

Myotonia physiologica neonatorum is a term applied by Hoch- 
sinp:er to the normal tendency of the newly born infant to flex the 
fingers, arms, and lo\ver extremities. There is a slight rigidity 
which is a hypertonicity of the muscle, and which lasts until the 
third month. The position closely resembles that of the extremities 
of the foetus in utero. The myotonia is exaggerated if the infant 
becomes ill with any intercurrent affection, such as syphilis. The 
condition cannot be mistaken for tetany if the differences between 
the normal and the abnormal states of the peripheral nerves are 
borne in mind. 

CONGENITAL STRIDOR OF INFANTS. 

(Thomson.) 

This rare condition has for a long time been classified by writers 
as a mild form of laryngismus stridulus. I have seen one case in 
which there was also laryngismus. The affection is a distinct one, 
is generally congenital, and appears soon after birth. Some years 
ago, I presented a case of the kind before the Pediatric Section of 
the Academy of Medicine of New York. Since then I have seen a 
number of cases. Thomson has fully described and studied the affec- 
tion. The infixnt is usually in other respects normal, but I have seen 
the condition in infants with signs of rachitis. The ages of the patients 
varied from nine weeks to twelve months. In one case there was a 
history of attacks of laryngisnuis stridulus, occurring shortly after 
birth. In most of the cases, the symptoms were noticed soon after 
birth. The respiration is more or less noisy, being sometimes scarcely 
audible and at other times so loud as to be heard at some distance. 
Inspiration is accompanied by a peculiar croaking, grunting noise. 
As a rule, expiration is noiseless, but it may be accompanied by a 
grunting sound, there being short intervals in which no sound is heard. 
The infants are not at all disturbed by the condition. They sit and 
play, emitting this peculiar croak while breathing. In mild cases, 
nothing is seen in the thorax. I have, however, seen the drawing 
inward of the suprasternal region which Thomson describes. In one 
case the noise was louder at night. If the stethoscope is held over 
the situation of the vocal cords, it will be ascertained that the sound 
is produced in the larynx and not in the pharynx. 

The causation is obscure ; the theory advanced by Thomson is 
that there is an ill-coordinated spasmodic action of the muscles of 
respiration, choreiform in character and similar to that present in 
stammering. This influence acting on the epiglottis from birth causes 
a deformity of the organ, which' in turn perpetuates the crowing noise. 
Others have attributed this condition to the presence of an enlarged 



LARYNGISMUS STRIDULUS. 785 

thymus (Variot). Some of these infants are distinctly lymphatic, 
and Hochsingen has lately with .r-ray demonstrated what he believes 
to be an enlarged thymus in many of the eases of laryngeal stridor 
coming under his notice. He believes the condition due to an 
enlarged thymus, and suggests that the term " Asthma thymicum '^ 
be api)lied to these cases. Lee and Refslund have published two 
cases with autopsy in which laryngeal stridor existed from birth and 
in which there was an anatomical malformation of the epiglottis. 
This consisted in a folding of the epiglottis laterally, so that the 
aryepiglottic folds were almost in contact. The superior opening of 
the larynx was thus covered by the deformed epiglottis in such a way 
that respiration took place through a mere slit of epiglottis, hence the 
grunting or sawing noise. I have recently published a case of 
laryngeal stridor dying of intercurrent pneumonia. This case showed 
the same malformation of the epiglottis described by Lee and 
Refslund, and would support the theory of anatomical deformity as 
a causative factor in these cases. Toward tlie second year of life 
the condition gradually disappears spontaneously. 



LARYNGISMUS STRIDULUS. 

{Spas7n of the Glottis.) 

Laryngismus stridulus is a spasmodic functional nervous dis- 
order of the glottis, involving the muscles of inspiration and 
expiration. 

Occurrence. — The affection is more frequent in boys than in 
girls. It is most common in the first year of life. The majority 
of the cases occur before the end of the second year. Kassowitz 
found 348 of 370 cases to occui* before that time. It may occur in 
the newly born infant (Henoch, Kassowitz). Most of the infants and 
children affected by this disorder are subjects of rachitis and also 
show signs of craniotabes. Henoch estimates the frequency of rachitis 
at 75 per cent. Only one of the cases of Kassowitz did not show its 
signs. All but 48 showed craniotabes. On the other liand, Boral 
shows that 4 per cent, of all children with rachitis have laryngismus 
stridulus. 

The etiology of this affection is obscure. Although rachitis is 
so frequent an accom])animent of the disorder, it may not yet be 
assumed that it is the exciting cause. Craniotabes, which is a part 
of the symptom-com])lex, has been regarded as the cause (Elsasser). 

Escherich, Loos, Gee, and Ganghofner have placed laryngismus 
stridulus in the same category as tetany, and trace it to the same 
exciting cause. Reflex irritation from the stomach acting through 
the vagus, is the theory of Baginsky. In many cases which have 
terminated fatally an enlarged thymus has been found. On the 

50 



786 BISEASES OF THE NERVOUS SYSTEM. 

other hand, there have been post mortems which showed a rather 
small thymas and slightly enlarged broncial nodes (Baginsky). 

Morbid Anatomy. — No definite study has been made of the 
changes found in the fatal cases. Most cases show oedema of the 
brain and some fluid in the ventricles, rachitis slight or pronounced, 
the thymus small or enlarged, and the lymph-nodes slightly enlarged. 
The cases with enlarged thymus thus far published have not been con- 
vincing. Children with enlarged thymus die of other disorders, and 
without having had during life any symptoms of spasm of the glottis. 

Symptomatology. — The spasm or paroxysm comes on suddenly. 
Without the least warning, the child throws the head back and 
stops breathing ; the face becomes livid, the arms are flexed and the 
hands clenched. No respiratory movement takes place for a few 
seconds. There is then a long-drawn whistling or crowing inspira- 
tory sound. This is the classical form of spasm of the larynx. 
The paroxysm may begin with a piping, inspiratory sound. Apnoea 
lasting for a varying length of time succeeds, and is followed by a 
loud or silent expiration. Apnoea may appear first, and be followed 
by several noisy explosive expiratory movements, w^hich may be 
succeeded by several noisy crowing inspiratory sounds. The pic- 
ture is usually that of spasm of the glottis as first described, in 
which the breathing stops entirely. The attack may come on 
during absolute quiet or during sleep, the onset of the attack causing 
the child to wake. The paroxysms may be brought on by excite- 
ment, a draught of air, or by pressure on the larynx. They are 
of all degrees of severity. Some infants show a form which is 
very disquieting. In a fit of crying the child takes a number 
of noisy inspirations and expirations, and then stops breathing, 
becomes cyanosed, clenches the hands, and threatens to pass into an 
eclamptic paroxysm (expiratory apnoea), when suddenly a deep 
inspiration occurs and the danger is passed. Some cases of the 
classical form have eclamptic seizures. There may be convulsions, 
especially in the form described as expiratory apnoea. One of my 
cases was that of an infant a year old, one of twins. The infant 
was anaemic, and showed marked signs of rachitis and craniotabes. 
It was in apparent health until the eighth month of infancy, when 
attacks of respiratory apnoea appeared at first at intervals of three 
weeks, and finally daily. The infant during a crying-spell would 
stop breathing, become cyanosed, the left hand and arm and lower 
extremity and muscles of the face contracted in tonic spasm, during 
which the heart became very slow in action and irregular. The 
left-sided spasm lasted for a few seconds, and then the infant relaxed 
and quietly passed into a sleep, from which it awoke in a few moments. 
In all of these cases there is the ever-present danger that the glottis 
and the muscles of respiration, including the diaphragm, will fail to 
relax, thus causing death with convulsions. The number of attacks 



EPILEPSY. 787 

of spasms of the glottis may reach twenty or thirty a day, or they may 
be very infrequent, occurring only once every few days, wrecks, or 
months. In all the forms, including the classical one just detailed, the 
spasm involves not only the glottis, but also the diaphragm and other 
muscles of respiration. The infants may show no symptoms after the 
paroxyms. On the other hand, some infants seem to be overcome and 
pass into a stupid state lasting for fully ten minutes. It is difficult 
to estimate the degree of consciousness during an attack, but even in 
the mildest forms there may be a momentary loss of consciousness 
(Henoch). Most cases show the facial and Trousseau symptoms of 
tetany and increased irritability of the peripheral nerves. 

The prognosis of spasm of the glottis is good. The danger lies 
in the eclampsia, during w^hich death may supervene. 

The diagnosis is not difficult. There are all degrees of severity 
of the spasm, ranging from partial to complete closure of the glottis. 
In the latter form a rachitic infant in a paroxysm of crying is fre- 
quently heard to give several inspiratory crowing sounds without hav- 
ing any further symptoms. There is a species of laryngeal inco- 
ordination. These cases may at intervals develop typical paroxysms. 
The parents should be warned of this possibility. The forms of 
spasm of the glottis which have just been described should not be 
confused with spasm or difficult breathing due to pressure of a retro- 
pharyngeal abscess or suppurating gland upon the larynx. 

Complications. — Pertussis may complicate a case of spasm of 
the glottis. Cases thus complicated give a grave prognosis (Henoch). 
Tetany has been elsewhere mentioned as an accompanying condition. 

Treatment. — During the Attack. — The infant is carried to an 
open window. A draught of air is allowed to blow in its face or a 
few drops of water are thrown in the face. This is done to excite 
a reflex relaxation of the glottis. The head should be held low, as 
in ordinary eclampsia. If relaxation of the glottis does not occur 
and convulsions set in, a few^ drops of chloroform may cause the 
muscles of respiration and those of the glottis to relax. Intubation 
and tracheotomy have been performed at this crisis, when the breath- 
ing threatened to cease permanently. If, however, as sometimes 
happens, the muscles of respiration are also involved, the paroxysm 
will occur with the tracheotomy tube in the trachea. Stork has 
published a case in which the insertion of a tracheotomy tube had 
not the least influence on the paroxysms. This is a very important 
observation, and raises the question of the propriety of intubating 
or performing tracheotomy. On the other hand, cases have been 
intubated and resuscitated with artificial respiration (Pott). In the 
intervals, the treatment should be chiefly directed toward the rachitis. 
The feeding should be carefully attended to ; the infants should, if 
possible, be breast-fed. Bottle-fed infants should be fed on raw 
milk, beef-juice, orange-juice, cereals, and eggs. The medicinal 



788 DISEASES OF THE NERVOUS SYSTE3I. 

treatment which in my hands has given the best results has been 
the administration of an albuminate, or peptonate of iron or man- 
ganese in full doses. To prevent the recurrence of the laryngismus 
or apnoeic attacks, full doses of the mixed bromides are given. To 
an infant one year of age as much as 5 grains of the mixed bromides 
of sodium, potassium, and ammonium are given three times daily, 
and continued over some period of time. Under this medicinal treat- 
ment I have been able to control apnoeic attacks. In my hands the 
administration of phosphorus has not been attended with any suc- 
cess. 

Bathing in cold water has not in my experience been productive 
of good results. 

EPILEPSY. 

Epilepsy is not a disease peculiar to iufancy and childhood. It 
is discussed here simply to emphasize the peculiarities of the affec- 
tion as seen in children. It is a true disease of the nervous system, 
and has nothing in common with and no demonstrable relationship 
to infantile convulsions. Fifteen per cent, of the cases of epilepsy 
occur before the fifth year of life. Henoch has seen a case in an 
infant one year of age who had convulsions beginning with a cry 
and during which the infant bit the tongue. He describes another 
case in a child three years of age, in which the attack began with 
vertigo. In another case, in a child three years of age, the patient 
fixed a point and ran blindly toward it. The latter appears to have 
been a case of ^' procursive epilepsy. '^ 

Etiology. — According to Gowers, in t^vo-thirds of the cases of 
epilepsy in children the })arents are neurotic and hysterical. Chorea 
in the mother will often manifest itself in epilepsy in the child. 
Infantile palsy or traumatism is more frequently than heredity the 
cause of epilepsy. Epilepsy following slight palsy is likely to be 
mistaken for hereditary epilepsy. 

Symptoms. — In children, as in the adult, there are no symptoms 
in the intervals between the attacks. Only such results of attacks 
as a bitten tongue or local traumatism are seen. There are, as in the 
adult, two distinct forms of e])ilepsy — grand and })etit mal — between 
which there may be all variations partici])atiug in the peculiarities 
of both forms. In grand mid there is the aura, sensory or psychic ; 
it is present in a large percentage of the cases in children. 

Baginsky calls attention to a case in which e])igastric ])ain Avas 
the aura preceding the attack. The other forms of aura are numb- 
ness and tingliug of the extremities, general restlessness and irri- 
tability and auditory phenomena in which a peculiar cry of an animal 
is perceived. There may be a hissing sound. An aura referred to 
the sense of taste is very rare, and most neun^logists do not make 



EPILEPSY. 789 

note of having found it in any case. In children the perception 
of peculiar odors just prior to the attack occurs as a form of aura. 

After the aura, the attack begins with a cry followed by sudden 
loss of consciousness and tonic or clonic spasm of the muscles, which 
may be unilateral, general, or partial. The pupils dilate ; there is 
spasm of the respiratory muscles and those of the jaw, as well as 
foaming at the mouth and biting of the tongue. The spasm then 
relaxes, the movements become first clonic and then intermittent, 
there is involuntary passage of urine and feces, and consciousness 
gradually returns, the patient passing into prolonged stupor and pro- 
found sleep. Some of these symptoms may be absent, but the loss 
of consciousness, dilated pupils, spasm, and the succeeding profound 
sleep are constant. In the majority of cases, the presence of any two 
of these will be sufficient for making a diagnosis. 

Convulsions. — General convulsions indicate hereditary epilepsy. 
Convulsions may at first be partial, but in the majority of cases 
eventually become general. Partial convulsions indicate disease in 
the motor areas. The attacks taking the form of petit mal may 
be so slight as to be mistaken for fainting spells. Such attacks 
may occur in young children. One of my cases was in a child five 
years of age. An epileptic spell is momentary ; a fainting spell is 
gradual, there are no vasomotor disturbances, and the pupils do not 
dilate. Henoch and others record cases in which the children 
momentarily stop the occupation in hand, stare into vacancy, and 
then recover themselves without having any recollection of the inter- 
ruption. In other cases there is an irritable attack or mild maniacal 
outbreak. In .some cases the child passes into a state of mental 
confusion in which it performs acts unconsciously. Attacks of 
double consciousness or narcolepsis are rare in children (Sachs). 

Attacks of grand mal are sometimes associated with a rise of 
temperature. A case recently came under my observation in which 
a girl of eight had as many as forty convulsive seizures in twenty- 
four hours. There was a slight rise of temperature which could not 
be traced to any cause other than the convulsions. Thomson and 
Oppenheim have shown that there are a concentric limitation of 
vision and a diminution of general sensibility for some time after the 
epileptic attacks. 

Diagnosis. — Epilepsy must be differentiated from syncope, 
hysteria, post-hemiplegic convulsions, and tumor of the cerebrum. 
Tlie peculiarities of an attack of syncope and hysteria have been 
dilated upon. The post-hemiplegic convulsions will, in the intervals, 
reveal the paralyses and contractures with increase of deep reflexes. 
Attacks of convulsions caused by tumor are confined to groups of 
muscles if the tumor is in the motor area, and are combined with 
optic neuritis if the chiasm is directly or indirectly the seat of pressure. 



790 DISEASES OF THE NERVOUS SYSTEM. 

With tumor, there are in the intervals peculiarities of the gait 
which aid in diagnosis. 

The treatment of epilepsy is essentially the same in children as 
in the adalt subject. 

PAYOR NOCTURNUS. 

{Night-terrors. ) 

There are two forms of this affection — the primary or idiopathic 
and the symptomatic form. In both, the children retire to sleep 
and after an hour or two suddenly awaken from deep slum- 
ber with a shriek or cry. They are pale, greatly terrified, and 
grasp at the empty air. In incoherent, broken phrases they try 
to collect their thoughts. Some children see terrifying visions and 
either cling to the bystander for protection or try to get out of 
bed to escape an imaginary danger. After being quieted the 
children fjill asleep, and when questioned the next morning have 
no distinct recollection of what has occurred. These attacks may 
occur every night for days, weeks, or months. They rarely occur 
twice in the course of the same night. 

The idiopathic form of this affection may occur in children 
who are naturally of a nervous temperament without any apparent 
exciting cause. I have seen it in children who were distinctly the 
opposite of nervous, and who were well nourished and good natured. 
The night-terrors may follow epilepsy or they may be so severe as 
to be the exciting element in precipitating an attack of chorea. 
Children sometimes have real hallucinations, which may be present 
even during the day (Henoch). It may, however, be said that 
hallucinations during the day are really not included in the idio- 
pathic form. This affection occurs chiefly up to the time of 
second dentition. Forms of terror in older children are hysterical. 
Adenoids are supposed to be an etiological factor, but this is doubtful. 
It is only in the symptomatic form that children, after having com- 
mitted some error in diet, awake with the symptoms above described. 

The prognosis is good. The affection never precedes insanity. 
It subsides under treatment or disappears spontaneously. 

Treatment. — In the symptomatic form, the meals should be so 
arranged that the lightest repast is that taken in the evening. In 
the idiopathic form, bromide of potassium is most useful. It is 
administered in one dose, an hour before retiring. The children 
should not be too active mentally during the daytime. Visitors 
should be restricted to certain hours. Play and sport in the open 
air are indicated. The school tasks of older children should be 
completed in the afternoon. 



CHOREA. 791 

CHOREA. 

{St. Vitu^ Dance; Sydenham's Chorea.) 

Chorea is a nervous disease characterized by irregular involuntary 
movements or twitchings of some or all of the muscles of the body. 
It is accompanied by muscular weakness and mental disturbances. 
In some cases there is endocarditis. 

Classification. — Chorea minor is an acute disease described by 
Sydenham. Chorea major is a hysterical disorder ; under this head- 
ing are included the chorea electrica, and the dancing mania with 
rhythmical motions, of the Middle Ages. 

Chorea insaniens is the fatal form of acute chorea minor. 

Laryngeal chorea is a hysterical affection (Gowers). 

Choreiform affections or pseudochoreas comprise the cases of tic 
convulsif of French writers and other forms of habit-spasm, local 
or general. 

In addition there are forms of chorea which are symptomatic 
or secondary to infantile palsies. Huntington's chorea is a chronic 
progressive affection of a hereditary nature. 

All these forms of chorea except chorea minor and insaniens 
should be excluded from the category of Sydenham's chorea. 

The epidemics of so-called chorea, occurring in schools, are prob- 
bly hysterical disorders which are the result of imitation and not 
true Sydenham's chorea. 

Frequency and Etiology. — Chorea is more common among 
female than male children. Of 554 cases collected by Osier, 
70 per cent, were of the female sex. It rarely occurs before the 
fourth year. Starr's statistics of 1400 cases show 8 at the third 
year. Cases are recorded as occurring in newly born infants, but 
are not accepted by all authors as authentic. The disease is most 
common from the fifth to the fifteenth year. Fifty per cent, of 
Starr's 1400 cases occurred before the tenth year, and 75 per cent, 
from the fifth to the fifteenth year. Of 83 cases of chorea occur- 
ring in my ambulatory and hospital service, 23 were of the male 
and 60 of the female sex. Ten children were under the age of five 
years, and 67 cases occurred from the fifth to the tenth year. Thus, 
the greatest frequency is at the latter period. Only one case occurred 
in a very young child (two and one-half years). The disease is 
found in children in all walks of life. Children of a nervous, 
ambitious temperament with a hereditary neurotic history are more 
prone to contract this disorder than those of a more equable dispo- 
sition. It is therefore more common in towns and large cities 
than in country districts. In some cases there is a history of 
fright or traumatism, either immediately preceding an attack or 
coincident with its onset. It is as yet impossible to say, how- 



792 DISEASES OE THE NERVOUS SYSTEM. 

ever, whether there is any relation between chorea and these occur- 
rences. They may have some influence in developing latent tenden- 
cies to the disease. An attack will often be initiated by a scolding 
or chastisement on the part of parents. The spring months show the 
greatest number of cases, the least number occurring in the late 
autumn. There also appears to be a correspondence in the preva- 
lence of cases of chorea and rheumatism at certain pei'iods of the 
year (Osier, Lewis). The relation of a condition of lymphatism 
(adenoids or nasal catarrh (Jacobi) ) to true Sydenham's chorea is 
not generally accepted. Errors of refraction in the eyes also seem 
to be a predisposing cause of the outbreak of choreic attacks, 
(de Schweinitz). These can scarcely be regarded as a direct cause 
of Sydenham's chorea, but acute articular rheumatism may be so 
considered. Rheumatism seems to run in families in which the 
children have chorea. Osier finds that 15 per cent, of his cases 
are of such families. Of the subjects of chorea, fully 21 per cent, 
show a history of rheumatism (Osier). These figures corre- 
spond more or less to the statistics of Townsend, 21 per cent.; 
Starr, 21 per cent, in 1400 cases; and my OAvn cases, 18 per cent. 
Crandall gives the highest frequency of rheumatism in cases of 
chorea (54 per cent.). In the majority of cases the rheumatism pre- 
cedes the chorea (See). I have seen one case of chorea preceding an 
attack of rheumatism in a child four years old. I believe that, with 
cases of rheumatism of the acute articular type, there should also be 
included those of articular pains without swelling of the joint. The 
forms of rheumatism with chorea giving the so-called subcutaneous 
fibrous rheumatic nodules are rare in this country (Osier). 

Chorea may complicate any acute infectious disease, such as 
scarlet fever, whooping-cough, measles, diphtheria, typhoid fever, 
and forms of sepsis. There are, however, no definite data of the 
exact relation, if there be such, between chorea and the infectious 
diseases. The theory that an attack of any of these diseases will 
cut short an attack of chorea is not borne out by clinical experience 
(Henoch). 

Morbid Anatomy. — The pathology of chorea is still incomplete 
and can therefore be merely indicated. Hypersemia of the brain 
and cord were found by Pye-Smith and Ogle. Anaemia and prolifer- 
ation of connective tissue were recorded by Steiner. In the cases of 
Meynert there was hyaline degeneration of the nerve cells of the 
central ganglia. Flechsig mentions hyaline degeneration of the 
lenticular nucleus. Dana studied some cases in which he found 
hypersemia of the brain, and degenerative changes in the walls of 
the bloodvessels of the white substance, with perivascular exudation 
and accumulation of leucocytes. Jackson has advocated the embolic 
theory (endocardial). At present there is a great preponderance of 
evidence in favor of the infectious theory. Berkeley found staphylo- 



CHOREA. 798 

cocci in the blood in a fatal case of chorea. In another case, 
Naunyn found cladothrix in the meninges and endocardial vegeta- 
tions. It is certain that just as rheumatism and endocarditis are 
infectious diseases, so chorea in many cases can only be understood 
on that theory. Cesaris-Demel has experimentally shown that the 
central nervous system is peculiarly susceptible to certain pathogenic 
micro-organisms and their toxins. The staphylococcus and its 
toxins when injected experimentally under the dura mater cause the 
formation of small foci of inflammation, and symptoms very similar 
to those of chorea. 

Symptoms. — Children will at the outset of this disorder exhibit 
mild symptoms of nervous irritability, will be cross, have outbreaks 
of peevishness and temper, will drop things, and be generally 
careless in their habits. There is sometimes a history of night- 
terrors or morose crying spells. There is likely to be loss of appe- 
tite ; headache is not uncommon, and there may be pains in the 
limbs or joints and general restlessness. The disease may begin in 
a certain set of muscles, or in the muscles of one-half the body and 
thence spread to the whole trunk. Of 301 cases of the statistics of 
Sachs, there was hemichorea or involvement of one set of muscles in 
67. Of Starr's 1400 cases, 951 were general and 449 unilateral, the 
right side being aifected more frequently than the left. When fully 
developed, the picture presented by these patients is so characteristic 
as to be easily recognized. On the other hand, the popular notion, 
so prevalent even among physicians, that every twitching is choreic, 
has led to grave errors. The following are the main symptoms : 

Motor. — The twitchings usually begin in the right hand, only 
rarely in the legs. After a time there are incessant, irregular, awk- 
ward twitchings of all the muscles of the body, which are intensified 
by volition. If the child is directed to stand still, with the feet 
together and the arms and hands held out at right angles to the 
body, the motions are intensified. If it is told to close the eyes, 
there is a distinct swaying of the body. The movements are not 
only irregular, but awkward. The patients trip in walking, upset 
their food and drink, and cannot button their clothing with ease. 
As a rule, the muscular twitching ceases in sleep, but it may per- 
sist. The muscular power is weakened, although distinct paralysis 
does not occur. The muscle is more paretic than paralytic. Some 
children let the arm hang at the side. There is wrist-drop when 
the children are asked to hold out the arms. The tongue is affected 
in all cases. Sachs places much diagnostic value on the choreic 
movements of that organ. When children are asked to show the 
tongue, they will protrude the organ with a jerk, then withdraw 
it and twist it here and there in the cavity of the mouth. When the 
tongue is held out quietly, fibrillary twitchings in the organ may be 
detected. Electrical reaction or irritability of the muscles in chorea 



794 



DISEASES OF THE NERVOUS SYSTEM. 



can be tested only when the disease is unilateral. In some cases there 
is no change. In others^ according to Gowers, there is a distinct 
increase in the galvanic and faradic irritability of nerve and muscle. 
The muscles of the hands, face, and extremities are all involved in 
the twitchings of the voluntary muscles. The involuntary muscles, 
such as the cardiac muscle, are not affected. Their involvement 
has long been a matter of discussion. 

Disturbances of sensation are not common. Children have the 
arthritic pains. Numbness, tingling, pricking, and anaesthesia of 
the pharynx are recorded. Attacks of multiple neuritis and epileptic 
seizures should be regarded as complications. The reflexes are not 
markedly affected. They may in rare cases be slightly diminished 
or increased (Henoch). Any marked change in the reflexes may 
be traced to changes of an organic nature, in the cord. The occur- 
rence of headaches or eye-strain as concomitant conditions has been 
referred to. 

Urine. — The urine may contain albumin. Cases with nephritis 
as a complication have been reported (Thomas). 

The speech is affected in 25 per cent, of the cases. The patients 
hesitate and mumble their words or there is difficulty of phonation 



Fig. 168. 


HOUR 3 6 9 12 3 6 9 12 3 6 9 12 3 6 9 12 3 6 9 12 3 6 9 12 3 6 9 12 3 6 9 12 3 B 9 12 3 6 9 12 3 6 9 12 3 6 9 12 3 6 9 12 3 6 9 12 


-;: 100° \ 1 1 i 1 1 1- 


<r 1 ^ ^ 


^^°m 1 Timml^^ ri rU m rmmT^ 


PULSE SSSSS S ?? K g g §|S gg S g 


RESP. S 2 2S S |S||£ 2| a| g 8||8| g g 8 Is 



Chorea. Recurrent attack of moderate severity. Systolic murmur over the aortic 
Fourteen days of the temperature is shown here. Child, twelve years of age. 



due to inco-ordinate action of the larynx. Laryngeal chorea, in 
which there is a distinct sound resembling a bark, is seen in rare 
cases. It is classified by Gower as a hysterical disorder, truly 
choreic. - I have never met a case of the kind in a child. Deglu- 
tition may be affected because of the muscular inco-ordination. 

The cardiac symptoms are the most important clinical feature 
of chorea. There is very little doubt, that in a fixed proportion of 
cases, rheumatism plays an important role and that the rheumatic 
poison, whatever it may be, expends its force upon the endocar- 
dium and pericardium. In 20 per cent, of the cases of Osier and 
in 12 per cent, of Starr's material, organic lesions of the heart 
were found. 



CHOREA. 



795 



The frequency of cardiac disease in chorea varies as given in 
hospital and ambulatory statistics. The severer cases come to the 
hospitals. The majority of the ambulatory cases are mild. Thus 
39 per cent, of my hospital cases showed a cardiac lesion (endocar- 
ditis), while only 1 3 per cent, of the ambulatory cases were similarly 
affected. There would thus be an average of 26 per cent, of both 
hospital and ambulatory cases. The lesions in simple chorea 
referable to the endocardium usually affect the mitral valve. Of 
17 valvular lesions, 14 occurred at the mitral valve (systolic). 
The aortic valve was affected in 3 cases (Fig. 168). Pericarditis 
occurred in one of my cases. In the majority of cases in which 
there was endocarditis either the patient or the parents gave a rheu- 
matic history. On the other hand, not all murmurs of the heart 
are organic. In 9 per cent, of Starr's 1400 cases, there were func- 
tional murmurs heard at the base and over the pulmonic area, 
early or late in the disease. A gentle blowing at the apex which 
is heard to the left of the sternum and is not conducted into the 
axilla or arteries is heard late in the affection, and is undoubtedly 
hsemic or myocarditic (Osier). I have heard these murmurs in 
many cases and have come to the same conclusion. Murmurs 
may also arise at the tricuspid orifice. The organic murmurs are, 

Fig. 169. 



12 3 a a 12 3 6 a 12 3 



1 101 

I 



m 



m 



z3 



:sz 



s?s 



m 



±± 



Chorea. Endocarditis. Previous attack six months prior to the present illness, which 
was of five weeks' duration before the above observation. Pains in the joints, especially the 
knee. This curve shows two weeks of the endocarditis. Recovery. Female child, five 
years of age. 



as stated above, produced at the mitral orifice in the greatest 
number of cases. They may arise in the course of the disease or 
may appear during a relapse. Such cases will show a temperature 
(Fig. 169). The temperature may after a time become normal, and, 
in a week or more, while the chorea is still in progress there may 
be a rise lasting for a day or more, after which it may then again 
subside to the normal. The temperature may be but a fraction of a 
degree above the normal, and the diurnal course may be distorted 
or subnormal (Jiirgensen). There is thus clinically a true endo- 
carditis. This form of endocarditis may pave the way for future 
chronic valvular disease. Under the heading of Chorea Insaniens, I 
have noted two fatal cases of this form of heart disease. Chorea 



796 



DISEASES OF THE NERVOUS SYSTEM. 



of the heart muscle is not clinically recognized. Pericarditis with 
endocarditis may occur in cases of recurrent chorea. I have seen 
two such cases. Functional disturbances such as palpitation and 
arhythmia also occur. 

Temperature. — There are some forms of chorea minor without any 
signs of endocarditis, which run a course with a slight temperature, 
the cause of which is undetermined. Some authors think that there 
may be a latent endocarditis in these forms of chorea (Henoch). If 
endocarditis is present, there may be a temperature only slightly 
above normal. In most cases of chorea, there is no temperature 
(Fig. 170). Fatal cases of chorea, with few exceptions, show^ signs 
of endocarditis. Osier has made a study of 80 such cases, and 
found only 5 which post mortem did not show changes in the 
valves. 

The mental symptoms an^ in some cases marked. The patients 
show apathy and depression. The children often, while they are 
under treatment, have spells of mental depression and fits of crying. 
It is only in the cases of insaniens, that delirium occiu'S. In severe 
eases, there is a period of more or less mental depression, extend- 
ing far into convalescence. 

The diagnosis of chorea minor is not difficult in the majority of 
cases. The picture is a very characteristic one. There are slight 



Fkj. 170. 


MOUR 3 6 » 12 3 6 8 12 3 6 » 1? 3 6 9 12 3 6 9 12 3 6 9 12 3 6 9 12 3 B 9 12 3 6 B 12 3 6 9 12 3 9 12 3 6 a 12 3 li !i 12 3 ti I'J 12 

100° J ^ J-X i 

-/^ A, -5^ — ' r~t 


a 98° 1£ -i- ^L 

(- 

9f = ___ii_±__z: z = z_ = = = __ = ___ 

PULSE § SgSgSSggS S S 1 g .-5 2 


RESP. S SS|3?3SS?3aS! a ?3 Is s ss 



Chorea, without endocarditis, two months in duration. No rheumatic history. Female 

child, nine years of age. 

twitchings, which so closely resemble habit movements that it is 
often not easy to come to a conclusion in regard to them. Sachs 
thinks that the twitchings of the tongue are a means of distinguish- 
ing the mild cases of chorea from cases of habit movements. If the 
patient is told to show the tongue, the tremors and twitchings of that 
organ and the facial grimaces at once become marked. The move- 
ments of the muscles are more rhythmic in hysteria than in chorea. 
True Sydenham's chorea should be distinguished from the chorea 
and athetoid movements seen in cases of infantile palsy. The his- 
tory of the cases, the paralysis, the condition of the reflexes and 



CHOREA. 797 

the contractures will be of assistance in making a diagnosis. True 
Sydenham's chorea should also be differentiated from cases of tic 
convulsif and habit movements. A diagnosis of chorea, made in a 
case which has lasted for a year or more, is open to doubt. 

The duration of chorea is variable. It may last from three to 
ten weeks, and may recur. The recurrent attacks are not neces- 
sarily any more severe than previous attacks. Fully one-third of the 
cases in some statistics show two or more attacks. Of Starr's 1400 
cases, 365, or 26 per cent., had relapses. One case had nine attacks. 
Starr thinks relapses less frequent in private practice than in hos- 
pitals. 

The prognosis of chorea minor is very good. Recovery is the 
rule, but in exceptional cases it may be delayed for fully three 
months. 

The treatment of chorea consists at first in giving the patient 
perfect rest and quiet surroundings. Children are put to bed and 
kept free from excitement. I do not think it necessary to isolate 
them, and it is not wise to do so, since they may, under such treat- 
ment, become melancholic. An ordinary amount of quiet, such 
as is prescribed in cardiac cases, is all that is usually necessary. 
The patient may be allowed to look at picture-books, but not to 
study or to read. A simple, easily assimilable diet is indicated, milk 
and eggs being the chief articles. A warm bath is given daily and 
the spine sponged with cool water, as some authors recommend. I 
have not found this necessary in all cases, and would advise it to be 
omitted if the children strongly object to it. Massage is of great 
value with anaemic children in whom the circulation is below the 
average and who have no cardiac disease and no temperature. 

Drugs. — Fowler's solution is used almost as a routine remedy in 
these cases. In my experience its curative effects are doubtful. I 
therefore prefer to give it in small tonic doses, rather than risk 
the ill effects of large dosage. There are cases in which any attempt 
to administer it causes vomiting, and which therefore do much better 
without it. In any case it should be well diluted. In this way 
larger doses can be given for a greater length of time than would 
otherwise be possible. 

Cases which show recent or old endocarditis or which have artic- 
ular pains should receive antirheumatic treatment. Alkalies to 
keep the bowels open, alkaline baths, and sodium salicylate are the 
remedies in use in these cases. 

If there is great restlessness, bromides should be resorted to. It 
is a very good plan to combine the bromides of sodium, potassium, 
and ammonium in one mixture. Trional given in grain v (0.3) doses 
several times daily is a very good remedy in this set of cases, espe- 
cially if there is wakefulness at night. 

If on account of the loss of appetite and general mental depres- 



798 



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sioii it is not possible to give any 
drugs, the children are simply 
kept quiet and given a nutritious 
diet. They frequently recover with- 
out the help of auy drugs. In ordi- 
nary cases there is no necessity of 
using opiates, such as codeine. Anti- 
pyrin in grain v. (0.3) doses has 
been recommended. I have not 
found it better than other remedies. 
Children who have recovered siiould 
be kept quiet for fear of a recurrence 
of symptoms. This is especially true 
of cases in which the heart has been 
the seat of a recent endocarditis. 

Chorea Insaniens. 

Chorea insaniens is a term applied 
to the severest form of chorea. A 
large number of these cases run their 
course with delirium and high fever. 
It occurs especially in female sub- 
jects. At the outset there may ap- 
pear to be nothing more than an or- 
dinarily severe chorea, but the patient 
rapidly becomes worse. Delirium 
with hallucinations sets in, finally 
giving way to incoherency and mania. 
The patients are in incessant motion 
and do not sleep at night. The fever 
may mount as high as 107° F. (41.6° 
C). The cases are in many instan- 
ces fatal. Osier gives a resume of 
some fatal cases. I have seen 2 fatal 
cases of this form. One case occur- 
ring during my service as interne at 
Bellevue Hospital was that of a girl 
of twelve, who died with symptoms 
very similar to those of acute mania. 
Another case, seen recently, was a 
boy of ten years, who had for two 
years previously suffered from ordi- 
nary chorea. He had a mitral re- 
gurgitant murmur. Two weeks before 
his death he was suffering from a 



FORMS OF TIC. 799 

mild recurrence of the chorea. While in that state he was operated 
on for adenoids and enlarged tonsils. Chloroform was administ^xed. 
Three days after the operation the boy was taken with a chill the 
chorea became worse, and there was fever. Examination of the 
heart showed endocarditis and pericarditis with dilatation of the left 
ventricle. In the second week the boy became delirious and did 
not sleep at night. He complained constantly of pain in the prse- 
cordium and tossed in bed. He died two weeks after the onset of 
the disease. There was throughout a high febrile movement. A 
third case was that of a boy six years of age, whose temperature- 
curve is herewith appended (Fig. 171). This case occurred in my 
hospital service. It was the boy^s third attack of chorea. He had 
chronic cardiac disease. In the final attack there was complicating 
pericarditis with effusion. The delirium was constant and the 
choreic movements incessant. He went into a typhoid state, but 
recovered, his mental faculties, however, being shattered. During 
the course of the pericarditis there was a polynuclear leucocytosis, 
and 45 per cent, haemoglobin. 

These cases are to be difPerentiated from cases of severe simple 
chorea, in which the movements are so incessant that the patients 
can with difficulty be kept in bed. In simple chorea there is no 
delirium and there is a period of quiescence at night. 

The treatment of chorea insaniens is symptomatic. The delirium 
and incessant restlessness are controlled with bromide of potassium, 
or sodium combined with chloral hydrate. The use of morphine is 
indicated in cases in which the chloral and bromides are ineffectual. 
Complicating endocarditis and pericarditis are treated as when 
primary. 

FORMS OF TIC. 

{Habit Movements or Spasms.) 

This affection is mentioned in this place to emphasize the im- 
portance of sharply differentiating its forms from true Sydenham's 
chorea. Tic is defined by Gowers as a habitual and conscious 
convulsive movement of one or more of the muscles of the body, 
reproducing some reflex or automatic movement normal to the indi- 
vidual. Osier has classified the forms of tic. There is first the 
ordinary form, in which young peoj)le or children develop a spasm 
of a group of muscles, generally of the face. Children do not 
have the form known as idiopathic spasm of adults in which the 
lower extremities are involved. There is contraction of a group 
of facial muscles, such as the orbicularis or the muscles about the 
nose. There are other forms of tic in which mental disturbances 
and explosive utterance of v\ords or syllables are prominent features. 
If the words are of an obscene character, the condition is called 



800 DISEASES OF THE NEEVOUS SYSTEM. 

coprolalia. In other cases the patients repeat words or sentences 
(echolalia). The so-called laryngeal barks of a hysterical nature 
are, according to most observers, to be classified as forms of tic, and 
not as laryngeal chorea. 

There is a fourth class, which includes those cases in which the 
subject before proceeding to any definite act, such as writing, feels 
impelled to blow on the fingers, pinch the nose, or strike the head or 
thorax. These actions may be regarded as harmless tricks. In 
another form of tic the patients feel impelled to touch objects, such 
as the floor or wall (delire de toucher of French writers). 

RHYTHMIC MOVEMENTS OF THE HEAD ASSOCIATED 
WITH NYSTAGMUS. 

{Head-nodding ; Spasmus Nutans; Gyrospasm.) 

Nystagmus alone is quite frequently observed in infancy and 
childhood. 

Rhythmic movements of the head associated with nystagmus 
constitute an uncommon aflPection. 

The derangement is functional and occurs in poorly nourished 
and rachitic infants whose nerve resistance is diminished. The 
majority of cases give a history of some preceding illness, in the 
course of which the infant has suffered from convulsions. The 
mothers may be of a nervous temperament. The phenomenon which 
at once attracts attention is a rhythmic oscillation of the head in a 
horizontal or vertical direction, or both. On close examination it will 
also be noticed that the eyes have a horizontal, vertical, or oblique form 
of nystagmus. Ebert, Cahen, Caille, Gee, Hadden, and Lewi have 
studied these cases. Lewi reported 6 cases from my clinic. The 
ages of the infants ranged from three to eighteen months. The 
movements were augmented when the infant focussed some at- 
tractive object. The nystagmus, if not marked, may be made 
apparent by holding an object to the right and upward for the infant 
to focus. Lewi as well as Caille found that the nystagmus ceased 
when the infant was blindfolded. In one case the movements con- 
tinued when the infant was in the recumbent posture. The eye and 
head movements were not synchronous. As a rule the eye move- 
ments were the more rapid. These observers did not agree with 
Hadden in finding that forcible restraint of the head stopped the 
nystagmus. I have been accustomed to see a number of these cases 
yearly. Some of the infants are quite bright and well nourished. 
This statement agrees with that which Thomson recently made. 
Three-fourths of the cases are under the age of twelve months 
(Thomson). 

The etiology of the affection is obscure. It is usually coincident 
with the period of dentition, but may appear as early as the third 



CONGENITAL INTERNAL HYDROCEPHALUS. 801 

month. Some of the infants live in dark, squalid quarters, and the 
affection has been attributed to eye-strain (;aused by the infant's 
attempts to fix a light as it lies in its crib. This theory would make 
the affection appear similar to that frequently seen in miners (Mag- 
nus). Some of the patients that I have seen lived in well-lighted 
quarters. 

Rachitis was present in most of my cases. Thomson's experi- 
ence; was similar. Henoch gives a physiological explanation of the 
combination of nystagmus with the rotary movements of the head, 
by pointing out that the root nuclei of the nerves of the muscles of 
tlie neck and thi-oat which rotate the head are adjacent to the ocular 
nucilei, and that any irritation of one set of nuclei may affect the 
otlier. This explanation has been generally accepted. 

Treatment. — The cases as a rule recover. They are given out- 
door air, correct food, and a general course of treatment for 
the rachitis. Phosphorus is given as in rachitis. I have also 
prescribed the bromides of ])()tassium and sodium, grains v (0.35) 
three times daily, but cainiot say tliat they have had curative 
effects. The cases certainly improved in time. The blindfolding 
suggested by Caille only stops the rliythmic movements of the 
head temporarily. 

HYDROCEPHALUS. 

( iJrop.sy of the Brain. ) 

Hydrocephalus or dro])sy of the brain is an abnormal accumula- 
tion of fluid in the subdural space, or in the ventricles of the brain. 
In the former case there is external, in the latter, internal hydroceph- 
alus. Hydrocephalus may be acute or chronic. It may also be 
congenital, secondary, or primary. The last-named form occurs in 
adult subjects (Delafield). Acute; hydrocH'phalus is described on 
page 328 under the caption of Meningitis Serosa. 

Congenital Internal Hydrocephalus. 

The accumulation of fluid l)egins in utero. The (juantity at birth 
may be small and may afterward increase. It may be large enough 
at birth to obstruct delivery. 

Etiology. — The (causes of the conditicm are unknown. Alcohol- 
ism, syphilis, and tuberculosis of tlie parents have been regarded as 
])redisposing causes, but infants thus affected may b(; born of per- 
fectly healthy parents. Sometimes several infants with this malady 
are born to one mother. 

Morbid Anatomy. — The (piantity of fluid accumulated in the 
ventrickis varies. The fluid is perfectly clear and has a specific gravity 

51 



802 



DISEASES OF THE NERVOUS SYSTEM. 



of from 1001 to 1009. It contains a trace of albumin and sometimes 
urea, sodium chloride, and cholesteriu. The weight may reach twenty- 
seven pounds. The fluid distends the lateral ventricles, the third 
and fifth ventricles, and the fourth to a less degree. The central 
canal of the cord may be dilated (Delafield). The corpus callosum 
is displaced upward. The thickness of the cerebral substance may 
be reduced to a few millimetres. The convolutions may be obliter- 
ated, as may also the basal ganglia. The aqueduct of Sylvius is 
dilated. The white matter of the brain suffers most. The mem- 
brane of that organ may be normal. The ependyma may be thick- 
ened and granular. 

The symptoms are the gradually increasing size of the head 
and the development of idiocy and paralyses as a result of 

Fig. 172. 




Congenital internal hydrocephalus. Infant, nine months of age. 



internal pressure on the nervous structures. The cranium en- 
larges so that it becomes disproportionate to the face, Avhich 
remains small. There is bulging of the occipital and frontal regions. 
The orbital plates take an oblique direction, causing the eyes to 
assume a peculiar stare (Fig. 172). The sclera is seen exposed above 
the cornea. The eyes are directed downward and are only partially 
covered by the eyelids. The sutures are forced apart and the fon- 
tanelles are widely open. The anterior fontanelle bulges and pul- 
sates visibly. The cranial bones may here and there show areas of 
thinness resembling those seen in craniotabes. The lambdoid suture 



CONGENITAL INTERNAL HYDROCEPHALUS. 803 

is flattened and the greatest diameter is across the temples. The 
head may attain an enormous size, the child being unable to hold it 
upright. The hair is scanty and dry. There may be strabismus, 
palsies, contractures, and convulsions. The eyes may not be on a 
level. Blindness may result. When the disease is progressive, 
idiocy develops. The children are very weak. 

Diagnosis. — Hydrencephaloid or spurious hydrocephalus is a con- 
dition which supervenes in acute exhausting states, such as that which 
follows diarrhoeal diseases. There is neither bulging of the fonta- 
nelles nor enlargement of the head. The fontanelle is depressed 
and the eyes are sunken. In certain forms of rachitis which are 
accompanied by craniotabes and cranial bosses over the parie- 
tal and frontal bones, there is frequently a very mild form of 
hydrocephalus. This condition is rarely progressive. It may be 
distinguished from true congenital hydrocephalus by the absence 
of progressive enlargement of the skull. The sutures may be 
patent, especially that between the parietal and frontal bones. The 
signs of rachitis are present elsewhere, and the children are, in 
contrast to the semi-idiotic subjects of hydrocephalus, very bright. 

In differentiating congenital internal hydrocephalus from the 
external form the history is of great value. External hydro- 
cephalus appears at birth and is not accompanied by bulging of the 
frontal and occipital bones. Mental deficiency is present from the 
outset. Late in the disease it may be impossible to distinguish 
between the two forms. A form of cranial syphilis is mentioned by 
Gowers as causing cranial enlargement, which, however, is never so 
marked as in congenital hydrocephalus. 

The diagnosis of congenital chronic internal hydrocephalus rests 
on the progressive enlargement of the cranium, the bulging in the 
occipital and frontal regions, and the flattening across the lambdoid 
suture. Acquired hydrocephalus rarely appears before the tenth 
month (Ireland). 

It is sometimes of interest to distinguish at autopsy between the 
congenital and acquired forms of hydrocephalus. Meynert has shown 
that in congenital hydrocephalus the lateral ventricles are dilated in 
their long diameters ; the posterior horn is dilated, so that it reaches 
within a few millimetres of the cranium. Acquired hydrocephalus, 
on the contrary, usually dilates the ventricles in their vertical and 
cross diameters. 

Prognosis. — Hydrocephalus is one of the most fatal nervous 
affections. There are mild forms in which the accumulation of 
fluid ceases after a certain time and recovery takes place, the intelli- 
gence being either slightly weakened or normal. In some cases the 
enlargement continues and death ensues from marasmus. In other 
cases the head becomes of enormous size ; the increase of fluid ceases ; 
the fontanelles and sutures close ; the unfortunate subjects have an 



804 DISEASES OF THE NERVOUS SYSTEM. 

euormous ossified skull, which they are unable to hold upright. 
They are partially idiotic or imbecile. They often, however, have a 
slight degree of intelligence, and may recite lessons, but are helpless 
in every way. 

The treatment of congenital internal hydrocephalus is alone of 
interest to the physician. The condition is hopeless. The injection 
of solutions of iodine .(Morton's fluid) has been tried with doubtful 
results. I have had 2 cases in which the ventricles were aspirated, 
fluid was withdrawn, and the head bandaged.- The operations were 
performed by an expert under antiseptic precautions. In neither case 
was the course of the disease affected. The fluid reaccumulated. 
Both patients died. I have performed lumbar puncture on several 
cases, repeated at short intervals without permanent benefit. In 
one case the temperature rose to 108° F. (42.2° C.) Cheyne- 
Stokes respiration set in, and the patient died. 

Cases in which Keen, of Philadelphia, inserted a permanent 
drain did not give encouraging results. Pott had an equally dis- 
couraging experience with that mode of treatmeut. Iodide of potas- 
sium administered internally is of doubtful value. In estimating 
the results of treatment, it should not be forgotten that a small 
percentage of cases cease to progress at a certain stage of the disease, 
and make a tolerably fair spontaneous recovery. 

External Hydrocephalus. 

External hydrocephalus may be acquired or congenital. If 
congenital, it follows an intra-uterine pachymeningitis or may take 
place because of the rudimentary state of the cerebrum (hydro- 
cephalus anencephalique). External hydrocephalus may be ac- 
quired, in which case it follows a pachymeningitis internal hsemor- 
rhagica or is the result of a meningitis in infancy. I have seen 
such cases. The congenital form of external hydrocephalus is very 
rare. Bokai records a case in an infant nine months of age. There 
was an accumulation of fluid between the dura and the pia mater. 
Both membranes and the falx were thickened, but there were other- 
wise no signs of inflammation. The infant had spastic symptoms. 
The diagnostic points in these cases are the uniform enlargement of 
the head and the bulging, especially in the temporal region. The 
axes of the eyes remain normal, the condition of those organs dif- 
fering in that respect from that seen in internal hydrocephalus, 
in which they are depressed downward. There may be slight 
exophthalmos. In Lewis Smith's case, the axes of the eyes were 
normal. 

In some cases of external hydrocephalus the head attains an 
enormous size. The disease cannot then be distinguished from the 
chronic internal form. In one of my cases external hydrocephalus 



AMAUROTIC IDIOCY. 



805 



followed meningitis. 



The head was uniformly large, the bulging 
over the temporal region being marked. The axes of the eyes were 
normal. The intelligence was low. 



Fig. 173. 




External hydrocephalus. 

In some cases of external hydrocephalus there is a slight internal 
hydrocephalus. 

AMAUROTIC IDIOCY. 

( Family Idiocy — Sachs.) 

This disease was first described by Warren Tay, an English 
oculist, in 1881. Among other symptoms, he noticed peculiar 
changes in the fundus of an infant suffering from the afPection. We 
owe the more extensive study of the affection to the American neu- 
rologist Sachs, who described his first case in 1887, not knowing 
that Tay and Kingdou had previously published theirs. Sachs has 
collected 27 cases in the literature, his own cases being included in 
the number. I have published 2 cases and have since seen a number 
of others. 

The etiology of the affection is still unknown. Alcoholism and 
syphilis do not appear to be very closely connected with its occur- 
rence. It appears to run in families. Frequently two or more 
children in a family are affected. 



806 DISEASES OF THE NERVOUS SYSTEM. 

Morbid Anatomy. — Tay-Kingdon, Sachs, and Van Glesen have 
studied the changes which occur in the nervous system. The first 
cases of Sachs were examined by Van Giesen, who found that the 
ganglion-cells of the cortex of the cerebrum, and especially the 
pyramidal cells, showed changes which indicated an arrest of de- 
velopment — an agenesis corticalis. There were no changes in the 
ganglion-cells of the cord and nuclear masses. There were degen- 
erative areas in the white matter of the lateral tracts. Hirsch has 
lately examined, by new methods, the brain and cord in a case 
of amaurotic idiocy. He found a uniform degeneration of the 
ganglion-cells of the gray matter throughout the whole nervous sys- 
tem. There were chromatolysis and displacement of the nuclei of the 
ganglion-cells toward the periphery of the cell-body, with a destruc- 
tion and breaking off of the dendrites and axis-cylinders. These 
changes were found throughout the gray matter of the brain and 
spinal cord. Hirsch thinks that these changes support his theory of 
the toxic nature of the disease. He is inclined to regard amaurotic 
idiocy as a form of infection originating in the intestinal canal. In 
a subsequent study upon cases which were in my hospital service 
Sachs agrees substantially with Hirsch in his anatomical findings. 

The symptoms are divided as follows: (1) Psychical disturb- 
ances tending to complete idiocy. (2) Weakness, resulting after a 
time in complete paralysis. (3) A normal, diminished, or increased 
state of the deep reflexes. (4) Increasing blindness with pathogno- 
monic changes in the region of the macula lutea (Tay and Kiugdon's 
spot), with optic neuritis. (5) Marasmus. 

The history of all the cases is practically the same. The infant 
is normal at birth. After from two to eight months, it is found to 
be indifferent to its surroundings. It rolls the eyes here and there. 
Although well nourished, it cannot sit up or hold the head upright. 
The head falls backward when an attempt is made to cause the 
infant to sit upright. Many of the infants cry constantly, at the 
same time making automatic facial grimaces. The lower extremities 
are weak and may exhibit complete paralysis (diplegia). In other 
cases, there may at intervals be a spastic rigidity of the lower extremi- 
ties, alternating with a lax condition. Convulsions are absent or 
may occur occasionally. The deep reflexes may be normal or dimin- 
ished. In the spastic cases they are increased. After the first year 
the infants become totally blind and completely idiotic. They finally 
become marantic, and die after the second year with the symptoms 
of advanced infantile atrophy. Occasionally there are nystagmus, 
strabismus, and hyperacusis. Deafness supervenes in many cases. 
The electrical contractility of the muscles may be normal or, as in 
one of my* cases, diminished. 

Ocular Changes. — The changes in the fundus of the eye described 
by Tay and Kingdon have been confirmed in the cases of Sachs, 
Koller, Heiman, and in my cases. They are invariably present at 



TUMORS OF THE BRAIN. 807 

some period of the disease, but may only appear late, as in the 
cases of Koller. Once present, they fix the diagnosis absolutely. 
The appearances consist of a cherry-red spot on a diffusely white 
area at the region of the macula lutea. Optic neuritis is also present 
toward the close of the disease. 

Diagnosis is not difficult after a study of the symptoms. If 
an infant is brought to the physician with a history of good 
health and intelligence up to a certain time, after which weak- 
ness and loss of interest in its surroundings set in, with inability 
to hold the head upright, the fundus of the eye should be examined. 
If Tay-Kingdon's spot is found, the diagnosis is fixed I have 
lately seen a number of cases in which the spastic symptoms were 
predominant. There were idiocy, increase of reflexes, complete or 
total blindness, and hyperacuity. I have watched infants with these 
symptoms for a long time and failed, even with expert aid, to find 
Tay-Kingdon's spot. In these cases there was probably a birth palsy. 

The prognosis is invariably fatal. Of the 27 cases of Sachs, 
only 1 lived to the age of six years. Most of the infants die before 
the end of the second year 

TUMORS OF THE BRAIN. 

Fully 50 per cent, of the brain tumors in infancy and childhood 
are tuberculous ; gliomata and sarcomata are next in order of fre- 
quency. Cysts are secondary to a hemorrhage or embolism. They 
may remain stationary for a long period, and then increase in size 
and cause symptoms. Males are affected twice as frequently as 
females ; two-thirds of the cases in male subjects are cases of gliomata 
and tubercle. Tumors are rare in the first six months of life. The 
largest number occur in the first decade. 

Location. — The medulla is rarely the seat of tumor. The cere- 
bellum is most frequently involved (50 per cent, of the cases, Ger- 
hard t, Peterson). The pars centrum ovale and basal ganglia are 
the parts next most frequently affected. 

Etiology. — The role of traumatism is not clearly understood. 
Gliomata are due to a proliferation of the neuroglia. Tubercle and 
sarcomata are secondary to foci elsewhere. Carcinoma is rare. In 
some cases of that growth the orbit is a focus of infection. 

Symptoms — Symptoms of pressure and irritation vary with the 
location of the tumor. A small but rapidly growing tumor will 
cause more pronounced symptoms than a large tumor of slow growth. 
Interference with the blood-supply and an increase in the quantity 
of fluid within the ventricles of the brain will cause the symptoms 
to vary. 

General Symptoms. — Headache. — This may in cortical and 
meningeal tumors be intense. It is of a boring, gnawing character, 
and is referred to the region of the tumor. Tumors in infants may 



808 DISEASES OF THE NERVOUS SYSTEM. 

attain great size previous to ossification of the skull. The bones 
of the skull are pushed apart and the sutures opened up. There 
is very little pain. Sleeplessness and restlessness, emaciation, and 
cerebral excitement are marked. 

]N"ausea and vomiting are prominent symptoms and persist for 
a long time. The vomiting is projectile and occurs independently 
of the ingestion of food. 

Vertigo is common and occurs with every change in the position 
of the head. It is a common symptom in tumors of the pons and 
cerebellum. 

Convulsions. — These may be localized or general. They occur 
when the cortex and motor areas are invaded, and eventuate in epi- 
lepsy of the Jacksonian type. In this form of epilepsy, the attack 
begins in the head or arm corresponding to the area of irritation, and 
subsequently becomes general. 

Optic neuritis and optic atrophy are important symptoms of 
intracranial tumor, but are not always present. When tumors are 
situated at the base of the brain, the symptoms appear early and are 
due to pressure on the chiasm. Optic neuritis is either double or 
more pronounced in one eye. 

The PULSE and respiration present no characteristic features. 
They show irregularities in rate. Respiration is affected only toward 
the close of the affection. 

Symptoms Dependent on the Location of the Tumor. — Cortical 
tumors in or near the motor areas cause convulsive seizures, 
which occur from the outset. Subcortical tumors will at first 
cause paralysis and, as they encroach upon the cortex, convulsions. 
With invasion of the cortex there are, in addition to convulsions 
with subsequent epilepsy, intense headaches. Tubercle, glioma, 
and gumma occur near the surface. Cysts and sarcoma are more 
deeply situated. 

The Frontal Lobe. — The tumors situated in this region cause 
stupidity and other marked changes in the degree of intelligence. 
There will be a perversion of the sense of smell, salivation, and also 
the drooling seen in idiocy. If the third frontal convolution is af- 
fected, there will be motor aphasia associated with agraphia — a rare 
condition in childhood. Tumors of the motor area will in the earlier 
stages cause cortical irritation, manifested in convulsive twitchings 
in the parts first paralyzed. There may be slight sensory or motor 
disturbances in an upper extremity and an occasional twitching of 
the arm, forearm, or thumb. 

The tumors of the parietal lobe cause sensory changes in 
the limbs of the opposite side of the body (Dana). If the white 
substance is the seat of tumor, there may be hemianopsia ; Wernicke's 
centre for conjugate movement of the eyes may be affected if the 
tumor is situated in the inferior part of the parietal lobe. 



TUMORS OF THE BRAIN. 



809 



Tumors of the occipital lobe cause homonymous hemianopsia 
with or without epileptiform convulsions, the latter being probably 
due to invasion of the cortex. 

Tumors of the temporosphenoidal lobe cause impairment of 
hearing on the side opposite to the lesion and sensory aphasia. The 
patient is able to speak, but cannot understand what is said or repeat 
spoken language. 

In tumors of the ganglia, there is involvement of the internal 
capsules. There are no convulsions and none of the choreic and 
athetoid movement seen in cortical tumors. 

Fig. 174. 




Pons tumor, showing nuclear palsies. Left abdueens paralysis. 

Tumors of the CRUS cerebri cause paralysis of motion and 
sensation on the opposite side of the body, and oculomotor paralysis, 
ptosis, and paralysis of the muscles of the eyeball, except the exter- 
nal rectus and superior oblique. There will be paralysis of the 
sphincter iridis and ciliary muscle. There may be paralysis of both 
sides of the body, double ptosis, and double oculomotor symptoms. 
The majority of cases are at first unilateral, later becoming bilateral. 
Loss of pupillary reflex, nystagmus, and cerebellar ataxia point to 
involvement of the corpora quadrigemina. 

Tumors of the pons cause unilateral or bilateral symptoms. 
There is hemiplegia or double hemiplegia with paralysis of the 
cranial nerves. There is paralysis of the third, fifth, sixth, sev- 
enth, and eighth nerves of the side of the lesion, with hemiplegia of 



810 DISEASES OF THE NERVOUS SYSTEM. 

the opposite side. There may thus be paralysis of the external rectus 
with facial palsy aud impairment of hearing on one side. If the 
nucleus of the sixth nerve is involved, there will be paralysis of con- 
jugate movement of the eyes toward the side of the lesion, while if 
it is not affected there will be only external rectus palsy of the side 
of the lesion not affecting conjugate movement of the other eye. 

Tumors of the medulla manifest themselves in bulbar symp- 
toms. There will be paralysis of the glossopharyngeal, vagus, 
spinal, accessory, and hypoglossal nerves. Thus there are unilateral 
or bilateral paralysis of the arms or legs, difficult deglutition, and 
disturbances of the respiratory movements and of cardiac action. 
In addition there Avill be spasm of the sternomastoid and trapezius 
muscles, and paralysis of the tongue, with atrophy, vomiting, poly- 
uria, and glycosuria ; optic neuritis occurs early, and there is severe 
occipital headache. Gummata in this region are not uncommon. 

Tumors of the cerebellum, which are usually of the solitary 
tuberculous form, are the most important intracranial growths in 
children. There will be occipital headache, vomiting early in the 
disease, and cerebellar titubation due to encroachment upon the 
middle peduncle. Vertigo is severe. The sixth, seventh, or eighth 
cranial nerves may be involved. There may be bulbar symptoms. 
Paralysis of the external rectus is very common in these tumors. 
Optic neuritis may be present. 

This list is by no means complete. The notes are given as 
concisely as possible. For further details the student is referred to 
the extensive special monographs on Brain Tumors. 

INFANTILE CEREBRAL PALSY. 

{Spastic Hemiplegia; Diplegia; Paraplegia.) 

Forms. — All clinicians of note now classify these palsies with 
regard to the time of onset. There are three varieties — the intra- 
nterine or prenatal, the birth palsies, and the post-natal forms. 

Brain palsy is a common disease of infancy and childhood, and 
has been known to occur up to the tenth year. Gowers and 
Osier are agreed that these palsies are most frequent in the first two 
years of life. They occur with equal frequency during the first and 
second years. 

The etiology of the affection is still very obscure, and differs in 
the various forms. In the intra-uterine or prenatal form, the causal 
influences are especially indefinite. The influence of maternal im- 
pressions, such as fright or worry, is uncertain. Other causes fre- 
quently cited are hereditary insanity or neurotic affections, an injury 
or blow to the abdomen, exhausting fevers during pregnancy, pneu- 
monia, typhoid fever, and ursemic convulsions. The role played in 



INFANTILE CEREBRAL PALSY. 811 

this disease by syphilis is as yet undetermined. That of alcoholism 
is also obscure. 

The birth palsies have been studied by Little and McNutt. To 
the latter we owe the first lucid post-mortem demonstration of their 
cause. She published several cases under the title of Apoplexia 
Neonatorum. It was demonstrated in this article that in easy 
labors as well as in prolonged and instrumental deliveries, hemor- 
rhages on the surface of the brain occurred and were the cause of 
subsequent palsies, with the resulting contractures and idiocy seen 
in such cases. 

The Post-natal Cases. — The etiology of these cases is still a matter 
of discussion. When Striimpel proposed the theory of an enceph- 
alitis similar to that occurring in infantile poliomyelitis, it was for a 
short time accepted. Clinically this theory was founded on cer- 
tain similarities between the spinal and cerebral affections. It has 
since been abandoned. It is found that many of the cases follow 
the acute infectious diseases, especially measles and scarlet fever 
(Gowers). Cerebral palsy may follow typhoid fever, pertussis, 
pneumonia, amygdalitis, cerebrospinal meningitis, gastro-enteritis, 
and traumatism to the skull. Infection or the presence of infec- 
tious disease cannot alone explain all the cases. The view most 
generally accepted is that the convulsion at the outset of the dis- 
ease causes the bursting of a vessel weakened by some form of 
degeneration (Osier). 

Morbid Anatomy. — Prenatal Cases. — There is porencephaly. 
Half a hemisphere, an entire hemisphere, or both hemispheres may 
be imperfectly developed. There are also certain defects in the cere- 
bral hemisphere to which is applied the term " Agenesis Corticalis.^' 
That is to say, there is imperfect development of the cortical gray 
cells, particularly those of the pyramidal type. The agenesis may 
extend throughout all parts of the hemispheres 

Birth Palsies. — The principal lesion is meningeal hemorrhage 
(McNutt). This may occur in areas over the cortex, or at the base 
of the brain. There may be a diffuse hemorrhage over the whole 
cortex of one hemisphere. The extravasation is, as a rule, most 
profuse over the motor area. 

Acute Palsies. — In these, there are found embolism and throm- 
bosis, or hemorrhage, the latter occurring mostly at an advanced age. 
As a result there may be atrophy of the cortex, sclerosis or cyst 
formations. Cysts are sometimes found later in life, there having 
been no previous symptoms (Gowers). They undoubtedly origi- 
nate in infancy. Some authors (Gowers) state that embolism, 
others that hemorrhage, is the pathological condition most frequently 
found in cerebral palsies of acute origin. The cause of hemorrhage 
in these cases is still a matter of speculation. There is certainly a 
change in the bloodvessels, but whether it is the fatty change seen 



812 DISEASES OF THE NERVOUS SYSTEM. 

in the bloodvessels in infancy and first pointed out by von Reck- 
linghausen, is a question. It may be that, given a vulnerable 
bloodvessel, heart disease or any infectious disease will predispose 
to hemorrhage. Cysts are likely to be found in cases in which 
there is idiocy. 

Symptoms. — In the prenatal cases the infant is born with the 
disease partially or completely developed. There are cases in which 
no symptoms are seen at birth. They develop during the first 
year. 

Birth Palsies. — In these cases, as in those of McNutt, there are 
symptoms of hemorrhage, disturbance of respiration, partial or 
complete loss of consciousness, and convulsions which may be 
general, or involve only one side of the body. The majority of 
infants thus aifected die soon after birth ; others live to exhibit 
various symptoms of defective development of the brain. There 
are paralyses more or less complete, with contractures, spastic 
rigidity of sets of muscles or of all the muscles, and increase of 
tendon reflex. 

The clinical history of the very mild forms of cerebral birth 
palsy is characteristic. Many of the cases are mistaken for cases 
of asphyxia neonatorum. After a normal delivery, the infant is 
noticed not to breathe deeply or regularly and to appear at times to 
cease breathing. If roused, it cries feebly, but again relapses into a' 
quiescent state, the breathing being irregular and shallow. It 
becomes slightly cyanosed, and while in this state may have re- 
peated convulsions. In other cases the infant is born apparently 
well, but after twenty-four hours the respirations become shallow 
and increase in frequency, and convulsions appear. These cases may 
recover. At about the time when the infants attempt to walk they 
may show slight spastic symptoms in the lower extremities, and have 
overextension of the foot and toes as soon as any attempt is made 
to place the feet on the ground. 

In severe cases unilateral paralysis and weakness of the muscles 
which support the head remain permanent. Spastic and paralytic 
symptoms are in some cases very marked. Athetoid movements 
of the extremities, with inability to grasp objects, contractures of 
the lower extremities, adduction of the thighs, mental defects, 
inability to sit upright, and oscillation in walking complete the 
later picture. 

Acute Cerebral Palsy. — According to Gowers, the onset is acute in 
two-thirds of the cases occurring before the end of the second year. 
The condition occurs with the same frequency in the first and second 
years, and is as a rule primary (Gowers). Although, as has been 
stated, it may follow the infectious diseases, there are frequently 
no premonitory symptoms ; the patient retires in good health and 
awakens with a hemiplegia. In more than half the cases the disease 



INFANTILE CEREBRAL PALSY. 813 

is ushered in with convulsions, generally unilateral. Whether these 
are present or not, there is unconsciousness lasting a few hours or 
for days, and sometimes fever and vomiting. When the child 
recovers the hemiplegia may be complete or the paralysis may develop 
slowly. The right side is more often involved (Osier). 

The symptoms in order of occurrence are as follows : 

Convulsions. — Coma and convulsions may be present at the outset, 
but may not develop until later in the disease. They are most 
likely to occur at the outset of the infectious diseases. If they per- 
sist into the later periods, epilepsy is likely to develop. I have 
seen a case in which as many as forty convulsions of an epileptiform 
character occurred daily. A condition of weak-mindedness or com- 
plete imbecility supervenes. Many of these cases are mistaken for 
true epilepsy. 

Paralysis. — In all forms of cerebral palsy, there may be hemi- 
plegia, diplegia, or paraplegia. As a rule, hemiplegia is of the right 
side (Osier). The facial muscles of the same side may be involved. 
There may be no facial paralysis. Monoplegia, especially of the 
leg, is rare. Diplegia is not common. After a time, contractures 
of the extremities occur. With these changes, there are charac- 
teristic disturbances of motion. There is the gait of the 
hemiplegic, slightly or markedly developed. As has previously 
been stated, the children may be born with contractures. A 
spastic paraplegia with athetosis in the upper extremities indicates 
the possibility that the arm may have been involved earlier in the 
disease. In about 20 per cent, of the cases, the face is involved 
at the outset. Motor aphasia is present. It is not present in birth 
palsies. According to Freund, hemianopsia is occasionally present. 

Disturbances of sensation are rare. 

Reflexes. — The deep reflexes are increased. There is no atrophy 
of the muscles as in infantile spinal palsies, or it is at most slight. 

With the ataxia, there are the athetoid movements first 
described by Hammond. These are sometimes marked. In some 
cases, there are cataleptic phenomena. In all cerebral palsies of 
whatever origin, paralysis, rigidity of muscles, contractures, and 
increase of the deep reflexes are constant features. 

Diagnosis. — Intra-uterine and birth palsies give a distinct his- 
tory of early development. If a palsy has developed a few months 
after a normal labor, it is to be classed as possibly intra-uterine. 
Both prenatal and birth palsies are likely to be diplegic or para- 
plegic. As a rule there is mental deficiency. Paralysis may be 
complete, or, as in one of my cases, scarcely noticeable. Double 
athetosis is indicative of double hemiplegia, and may even take the 
place of paralysis. Choreiform movements are frequently mistaken 
for chorea. They are unilateral and combined with exaggerated 
reflexes and partial, slight or marked paralysis. Aphasia of cerebral 



814 DISEASES OF THE NERVOUS SYSTEM. 

palsies is motor rather than sensory. Its presence precludes the 
possibility of the palsy's being of prenatal or of birth origin. 

The cerebral palsies are differentiated from the infantile forms of 
paralysis by the presence of contractures, rigidity, increase of deep 
reflexes, and occasionally by the presence of athetosis and chorei- 
form movements. In recent cases the absence of atrophy will also 
aid in diagnosis. 

Prognosis. — So far as prenatal and birth forms of palsy are con- 
cerned, no definite prediction in regard to the outcome can at first 
be made. Many of the cases of birth palsy die at the outset. Some 
escape with very slight paralysis. Others develop convulsions with 
subsequent epilepsy and idiocy. Contractures, diplegia, and double 
hemiplegia with spastic symptoms may develop. The acute cerebral 
forms may improve to such an extent that only slight paralysis, 
choreiform movements, or athetosis remain. In other cases im- 
provement is followed by a return of the symptoms, with convulsions 
and epilepsy. It is estimated that fully 45 per cent, of the cerebral 
palsies develop epilepsy, while the diplegic forms are less likely to 
do so. One convulsion is apt to be followed by others, and these 
in time by epilepsy and mental deficiencies. 

The treatment of cerebral palsy is ultra-conservative. Cases 
of birth palsy have difficulty in deglutition. Aid in keeping up the 
nutrition of the patient may be given by spoon-feeding or feeding 
with stomach-tubes (gavage). If there are convulsions, bromides in 
moderate doses are administered. The infant should be kept per- 
fectly quiet. In the acute cerebral cases, if hemorrhage is suspected 
rest and the application of an ice-bag to the head are indicated. 
Subsequent convulsions are treated with bromides. The bowels are 
kept open with calomel. In cases in which there is slightly 
marked paralysis, massage and the various forms of hydrotherapy 
are of great utility. The faradic current has much the same effect 
as massage. If contractures and choreiform movements supervene, 
the various orthopaedic appliances are of great practical utility. 
Where indicated, they should be used in connection with judicious 
tenotomy. Surgical interference has been practised in forms of epi- 
lepsy which simulate the Jacksonian type. The results are disastrous 
in young children, nor is permanent relief to be expected in older 
ones, 

FACIAL PALSY. 

( Bell 's Paralysis, ) 

Paralysis of the facial nerve is quite common in infancy and 
childhood. As in the adult, the distribution and etiology of the 
paralysis vary. 

The facial paralysis observed in infants who have been delivered 



FACIAL PALSY. 



815 



with forceps is a pressure paralysis. It may affect the upper or 
lower branches of distribution. The prognosis of this form of paral- 



FiG. 175. 




Facial paralysis, left side, rheumatic form. Girl, eight years of age. 
Fia. 176. 




Facial paralysis, rheumatic form, showing inability to close the eye. Girl, eight years of age- 

ysis is, as a rule, very good. Recovery takes place after a few 
weeks. Some cases do not thus recover ; there should therefore 



816 DISEASES OF THE NERVOUS SYSTEM. 

be some conservatism in prognosis. Congenital facial palsy may 
occur in the absence of any history of traumatism or pressure. 
Henoch records such a case in a boy of ten years. There was 
deafness on the side of the paralysis, but no history of disease of 
the ear. 

The so-called rheumatic form of facial paralysis occurs in infants 
and children, but rarely does so before the third year, and most 
commonly between the sixth and fifteenth years. The symptoms 
are the same as in later life (Figs. 175 and 176). 

Of greatest interest to the practitioner are the facial palsies 
which occur in infants and children as a result of ear disease or of 
inflammatory disease of the mastoid process. In infants a few 
months old, I have seen facial palsy due to otitis in one ear 
(Fig. 177). Henoch has seen cases in infants from three to five 

Fig. 177. 




Facial palsy complicating otitis. Infant, seven months of age. 

months of age. The facial nerve is aifected as it passes through 
the Fallopian canal. Caries of the bone, pus, or swelling in 
the vicinity of the canal, will cause this form of paralysis. It is 
therefore a species of pressure paralysis. There may be no dis- 
tinct collection of pus in the mastoid cells, but, when opened 
up, the mastoid is found to be filled with granulations. Tem- 
perature, tenderness, and redness over the mastoid should arouse 
suspicion. 

Bokai reports a case of retropharyngeal abscess in which the 
facial palsy was caused by pressure on the nerve as it emerged from 
the stylo-mastoid foramen. 

Another form of facial palsy is that seen in basilar disease of 
the brain. The facial palsy seen in tuberculous meningitis and 
sometimes in the non-tuberculous variety is of great diagnostic 



MULTIPLE NEURITIS. 817 

import. This paralysis is not always marked ; it is often a very 
slight paresis with flattening of the facial muscles on one side and 
accompanied by slight widening of the palpebral fissure on the same 
side. In connection with this symptom, a dilatation of one pupil or 
slight strabismus is exceedingly significant of basilar affection. In 
other words, in the forms of menlngitic facial palsy, the physician 
should be on the alert for changes in the contour of the face, since 
in many of these cases the patient is conscious only at intervals. 
In many cases, restlessness on the part of the patient will cause 
the slight flatness of the face or widening of the palpebral fissure to 
disappear. The patient should be watched unawares or w^hen at 
perfect rest. The facial palsies with cerebellar tumors and tumors 
of the pons have been referred to in the section on Tumors. 

Operative facial palsy in infants and children is likely to occur 
after the radical operation on the mastoid, if the operator is not a 
thorough anatomist. I have felt that this accident could be avoided. 
After an operation on the mastoid I have seen mild facial palsy, 
consisting of a very slight lagophthalmos with slight flattening of 
the facial muscles, which disappeared Avithin twenty-four hours. It 
was possibly due to pressure on the nerve during the operation. 
Facial palsy following a mastoid operation is, as a rule, due to 
actual traumatism to the nerve, and to its partial or total destruc- 
tion. The paralysis in such cases is permanent. 

The treatment of facial palsy in infants and children is deter- 
mined by the origin of the palsy, and is essentially the same as in 
the adult. 

MULTIPLE NEURITIS. 

This is an affection in which several or most of the peripheral 
nerves undergo degeneration of an acute type. The nerves affected 
are, as a rule, symmetrically distributed. 

Etiology. — The disease may be caused by the poisonous action 
of drugs, such as lead, arsenic, and alcohol. It follows the infectious 
diseases — measles, diphtheria, typhoid fever, influenza, and malaria. 
In such cases the degeneration is due to the action of bacterial 
toxins on the peripheral nerves. Cold is said to favor the onset of 
the disease. In many cases, it is impossible to fix upon any 
definite cause. 

Frequency. — If we except diphtheritic paralysis, affections of 
the peripheral neves are much less common in childhood than in 
later life. It is extremely rare in early infancy, though I have seen 
multiple neuritis follow measles, in which the nerves of the face, 
the eyes, the soft palate, the extremities, and trunk were involved 
in a child of fourteen months of age. When it does occur in child- 
hood, there is a strong hereditary predisposition, or the morbific 

52 



818 DISEASES OF THE NERVOUS SYSTEM. 

influence in the case has especial predilection for the peripheral 
nerves. 

Morbid Anatomy. — There is an early stage daring which there 
are hypersemia and swelling of the sheaths of the nerves, which may 
be the seat of minute hemorrhages. The nuclei of the sheaths are 
enlarged. There is an. increase of connective-tissue cells between the 
nerve-sheaths, and also of round and spindle-shaped cells between 
the nerve-fibres. The changes in the nerve-fibres are characteristic 
of nerve degeneration. The muscles may be the seat of parenchy- 
matous degeneration. The striation may become indistinct. In 
some cases there are also interstitial changes. 

The symptoms of multiple neuritis in children ai*e very charac- 
teristic. After an infectious disease, the child no longer walks with 
a steady gait, but may stumble and fall. After a time it is noticed 
that the patient does not care to stand, and the mother is unable to 
persuade it to do so. The child cries when put on its feet, which 
refuse to support it. There seems to be pain connected wdth an 
attempt to stand, and also on handling and pressing the muscles. 
After a time the child does not sit upright, but falls back or toward 
one side when put in the sitting posture. It finally becomes 
completely paralyzed. The paralysis is progressive and symmetrical. 
The child does not use the hands. The feet drop forward (foot- 
drop) and there is a very characteristic wrist-drop. The child lies 
helpless in the crib, una])le to move. Some of these patients cry 
constantly as if in pain. During this time there is good nutrition 
and the appetite is good. The muscles of the trunk are frequently 
aifected as well as those of the extremities. In these cases there is 
a species of paralytic lordosis when the child stands or sits upright. 
In a few cases the muscles of the eye are affected, and in fatal 
cases those of the diaphragm. 

The facial and hypoglossal nerves are rarely the seat of the dis- 
ease. The musculospiral and })eroneal nerves seem, as in polio- 
myelitis, to be affected. The reflexes are diminished and finally 
disappear. The dorsum of the feet and hands is slightly affected 
with oedema. 

Sensory Disturbances. — In si)ite of statements to the contrary, 
it is very diflicult in children and infants to elicit exact data as 
to the pain or sensory changes and their distribution. I have 
found evidences of pain on handling the children or attempting 
to make them stand or sit. The patients are restless at night, 
and cry most of the time, and it must tlierefore be inferred that 
they have pain. 

Course. — The majority of the cases make a complete or almost 
com])lete recovery. In a case which I watched very closely the 
reflexes were shnv to return, although the cliild began to sit upright, 
then to stand, and finally to walk. The gait in walking w^as very 



31 UL TIPLE NE URITIS. 



819 



peculiar. It was a sort of waddle, resembling that exhibited in 
congenital luxation of the hips. The boy, three years of age, 
finally made a complete recovery. 

As a rule, the symptoms increase in severity for from four to six 
weeks ; they then r(>trograde and improvement sets in. In some 
cases the development of symptoms is rapid, the diaphragm becomes 
affected, and the children die of bronchopneumonia. If the vagus 

Fig. 178. 








MuU.iple neuritis in a child two and one-half years of age. Shows the complete relaxation 
of the glutei muscles. Recovery. 

is affected, death occurs through cardiac failure. Diphtheritic cases 
are apt to be progressive and fatal. 

Diagnosis. — If the clinical picture is studied, the diagnosis is 
not difficult: The complete and absolute paralysis is, in its mode of 
onset and its symmetrical distribution with anatomical impairment 



820 DISEASES OF THE NERVOUS SYSTEM. 

of sensation of all kinds, so peculiar that it cannot be confounded 
with poliomyelitis. In the cases which I have seen the muscular 
atrophy was also less marked than in the latter disease. The very 
characteristic feature of the paralysis is its flaccidity. If the child is 
made to sit upright, the glutei muscles flare, as it were, outside the 
body-line and do not retain the tonicity of the normal muscle. 
There is nevertheless not much atrophy of the glutei. Landry's 
paralysis is so rare in infancy and childhood that it need not be 
considered in detail. 

The i)ain iu these cases is always marked, even in young children 
and infants. They cry when handled, and resist all examination. 
In older children pressure on the nerve-trunks at their point of 
exposure undcrncnith the skin, such as iu the popliteal space or in 
the sacro-iliac groove, is exceedingly painful. The com})lete re- 
covery in favorable cases without ])aralysis or paresis differentiates 
it from poliomyelitis. 

The treatment is palliative, since the disease is not only self- 
limited, but also tends to spontaneous recovery. The pain is 
relieved and the skin ke])t in good condition by massage. If the 
child is restless, it is treated in the ordinary way. There is no 
specific for the affection. Electricity is not recommended by those 
whose (>xperien(!e gives weight to an opinion. If contractures result, 
orthopedic appliances are indicated as in other ])aralytic diseases. 

ERB'S PALSY. 

( Ohstetrlml Palsy.) 

This form of palsy, which occurs in infants and children as well 
as in adults, is due to a neuritis caused by direct traumatism either 
to the nerves su])plying the muscles of the shoulder, or as in the 
newly born infant by traction or ])ressure on tlie brachial plexus 
(see Fig. 28). Krb showed that the point injured in these cases* 
is the spot between the scaleni at the exit of the iiftli and sixth 
cervical nerve roots. Duchenne, SeeligmiilkT, and Henoch have 
described these l)irth (;ases in infants. I have seen cases in older 
cliildren whic^h coi-respond to the adult cases. 

The symptoms are very (iharac^teristie. 'i'here is complete 
paralysis of the arm on the affected side. The child, if directed to 
raise the arm or forearm, is unable to do so. The fingers vxm be moved. 
Infants sometimes hold the ]iaralyz(Hl arm with the healthy one. In 
a few (5ases there seems to b(; ])ain, caused by the drag of the para- 
lyzed member on the shoulder. After a time there is atrophy of the 
deltoid and other muscles about the shoulder-joint, which causes the 
bony pr()minen(u\s to show markedly (Plate XXXI I.). The atrophy 
sometimes comes on very ra])idly. In infants and children it is 
impossible to reach any conclusion in regard to the intensity of pain 
and the disturbances of sensation. 



PLATE XXXII 




Erb's Paralysis in a Child Twonty-six Months of Age. 
Atrophy of the deltoid, subluxation of the arm; bony 
prominences marked. 



HEREDITARY ATAXIA. 821 

The cases should be diiFerentiated from cerebral birth palsies. 
Apart from the electrical reaction, the absence of hemiplegia or 
diplegia of a spastic nature with rigidity, the absence of increased 
reflex, and also of convulsions, all of which are present in birth 
palsies, will aid in ^He diagnosis. Later in life it may not be possi- 
ble to determine which form is present. 

The prognosis is good, but I have seen severe cases of obstetrical 
palsy which failed to recover. 

The treatment depends on the origin of the palsy. If it is 
obstetrical, the arm should be put in an apparatus to protect it from 
injury. After two weeks, friction, massage, and a mild electrical 
current of the faradic variety should be applied. If contractures 
develop later, splints should be constructed to counteract the ten- 
dency. On the whole, the management of the cases is based on the 
principles which govern the treatment of peripheral palsies. 

HEREDITARY ATAXIA. 

{Friedreich s Disease; Hereditary Ataxic Paraplegia.) 

This is a form of ataxy which frequently affects several members 
of the same fimily. Riitimeyer and Griffith collected 233 cases 
which were distributed in 107 families. In 38 cases there was a 
direct hereditary history. In the remainder, there was a history of 
alcoholism, syphilis, or consanguineous marriage. Sixty-five cases 
of Gowers were distributed among 19 families. Thus there was an 
average of 3 to each family. In some families there were 10 cases. 
Isolated cases are rare, aud occur, as a rule, only in children. The 
disease affects the sexes equally. Cases have occurred as early as the 
second year, and as late as the twenty-fourth, but are seen most fre- 
quently between the seventh and eighth years. 

Symptoms. — The onset of the disease may be gradual or abrupt. 
The first symptom is an impairment of co5rdination in the lower 
extremities. The patient is unsteady in walking, and stands with 
the feet wide apart. Some patients reel when the eyes are closed 
more than at other times. In other cases Romberg's symptom is 
absent. The feet show the peculiar deformity of pes cavus. The 
instep is high and the toes overextended. The movements of the 
arms next become ataxic. The speech becomes slow and halting. 
Jerking, nodding movements of the head set in. Irritability of 
muscle is absent from the beginning. The deep reflexes may be 
present at first, but finally disappear as in true tabes. 

Nystagmus is usually present, and may be a very early symptom, 
appearing simultaneously with the ataxic symptoms. The symp- 
toms connected with the speech may come on very late in the disease. 

Optic atrophy is never present, and the Argyll-Robertson pupil 
of tabes is absent. 



822 DISEASES OF THE ^'EEVOUS SYSTEM. 

Sensory disturbances, such as shooting pains, are rare, but may 
occur. There is no tendency to trophic joint-afFection as in tabes. 
The sphincters are normal. 

Muscular power, although normal at first, diminishes as the dis- 
ease progresses. There is atrophy of muscle. Spinal curvatures, 
talipes equinus, and equinovarus result. The loss of muscular 
power is sometimes limited to the lower extremities. 

The mental condition is generally affected. The children are 
slow at school. Imbecility has been recorded (Gowers). 

Course. — Once inaugurated, the disease is progressive, but 
it may remain stationary at any stage for some years. The dura- 
tion is extended over years. Gowers gives the period as ten to 
twelve years. The patients finally become bedridden, and, as a 
rule, die from intercurrent disease. The anatomical changes have not 
as yet been completely classified. This is due to the fact that in 
certain forms of hereditary ataxia resembling Friedreich's disease, 
Marie and Hoffrnann have described changes other than those found 
in typical cases of that affection. The changes in Friedreich's dis- 
ease consist in a diminution in the transverse diameter of the cord 
and a sclerosis of the posterior and lateral columns, involving the 
pyramidal tracts. The neuroglia and vessels of the tracts are in- 
volved ; whether this is due to an arrest of development of a con- 
genital nature has not been determined. 

Differential Diagnosis. — The disease should be differentiated 
from true tabes. In the latter, there are the Argyll-Robertson pupil 
and optic neuritis, the visceral crises and shooting pains, but neither 
head-nodding nor nystagmus. The lack of intelligence and the 
family history are characteristic of Friedreich's disease. 

Prognosis and Treatment. — There is no cure for the affection. 
The treatment is designed to relieve the symptoms. 



ACUTE ATROPHIC PARALYSIS. 

{Acute Anterior Poliomyelitis ; Infantile Paralysis; Essential Paraylsis of Children.) 

This is the most common form of paralysis in infants and chil- 
dren. It is a disease characterized by loss of voluntary power, 
taking place within a few hours or days. Some of the paralyzed 
muscles recover ; others undergo atrophy. 

Occurrence. — There is doubt as to whether the disease occurs in 
foetal life. Duchenne has reported a case at the twelfth day. Such 
early cases are apt to be cases of hemorrhage rather than of polio- 
myelitis. The majority of cases occurring during the first year de- 
velop after the sixth month, and three-fifths of the cases before the 
tenth year are found to occur during the first three years. It affects 
the sexes equally. 



ACUTE ATROPHIC PARALYSIS. 823 

The etiolog'y of the disease is still uncertain. Cases occasionally 
occur after exposure to cold, and after a traumatism or a psychical 
disturbance, such as fright. The relationship between these predis- 
posing elements and the disease is probably no more intimate than is 
the case in other affections. 

This disease is very frequent in the period of dentition, but 
since dentition has been regarded as a predisposing cause in most 
diseases, no close relationship is evident. It has been shown 
by Medin, Striimpel, and Zuppert that many of the cases of 
poliomyelitis occur after or during the course of the infectious 
diseases, especially measles, scarlet fever, and typhoid fever. It 
is probable that some toxin acting through the blood and blood- 
vessels causes the degeneration in the cord characteristic of the dis- 
ease. It is also probable that the epidemic occurrence of the affec- 
tion is due to its infectious nature. Medin, Pasteur, Sinkler, 
Putnam, Chapin, and Zuppert have reported epidemics. 

Symptoms. — There are four distinct periods in the development 
of the symptomatology : The period of onset, in which the symp- 
toms resemble those of an infectious disease ; the period of 
paralysis ; the period of retrogression, in which some of the para- 
lyzed parts recover while others remain permanently paralyzed ; 
and finally, the chronic state, in which there are permanent paralysis 
and atrophy. 

The Onset. — This is always acute. In most cases there are fever, 
vomiting, and diarrhoea. The fever may be slight (100 °F., 
37.7° C.) or may mount to 104° F. (40° C). 

Complete paralysis sets in after these symptoms have continued 
for a few hours or days. In other cases the paralysis first attracts 
attention, and is followed by fever and constitutional disturbances 
persisting for days. General convulsions may usher in the disease, 
and be followed by coma lasting for days. At the termination of 
the coma, the patient is found to be paralyzed. The onset some- 
times resembles that of cerebrospinal meningitis. There are head- 
ache, vomiting, fever, and rigidity, the paralysis becoming apparent 
after the subsidence of these symptoms. Other cases have abso- 
lutely no premonitary symptoms. The patient goes to bed in 
health, but in the morning is found to be paralyzed. Patients 
sometimes suddenly fall, and on being raised up are found to be 
paralyzed. These are probably cases of acute spinal hemorrhage. 
In older children pain in the course of the nerves may usher in the 
paralysis. Pains in the joints and back may succeed the paralysis. 
Such cases closely resemble those of peripheral neuritis. 

The Paralysis. — The paralysis consists of a loss of power, which 
is complete in two or three limbs or in parts of extremities. Seelig- 
miiller found the relative frequency of involvement to be as follows : 
the right lower extremity, the left lower extremity, the right upper 



824 DISEASES OF THE NERVOUS SYSTEM. 

extremity, and the left upper extremity, in the order named. All four 
limbs may be involved, or only a hand and a leg. If all four limbs 
are at first involved, there is weakness of the back. The patient 
cannot sit upright or hold the head erect. The cranial nerves 

Ftg. 179. 




Acute atrophic paralysis involving the left upper and lower extremities. 

escape, except in very rare cases, in which degeneration or inflam- 
mation involves the medulla and its nuclei. There may be symp- 
toms which simulate those of bulbar paralysis. 

Different sets of muscles may be involved. After the first onset 
of the paralysis, some of the muscles may recover. Thus a child who 
has been unable to sit up or move the arms will recover the power 
to do so. In such cases one leg only may remain permanently 
paralyzed. 

Paralysis may develop slowly in the course of one or two weeks. 
After that time it comes to a standstill. In a period of from one to 
three months either recovery will take place or the paralysis will 
be complete with accompanying atrophy. 



ACUTE ATROPHIC PARALYSIS, 825 

Atrophy in the paralyzed muscle is very characteristic of the dis- 
ease. It may be seen as early as the first week. Accompanying 
it, and appearing from the fifth to the seventh day, is the reaction 
of degeneration in the paralyzed muscle and nerve. The faradic 
and galvanic irritability of nerve and muscle are increased for the 
first two days. They then rapidly diminish, the former disappearing 
completely. The galvanic irritability remains increased for from two 
to six months ; it then diminishes, and if the paralysis is permanent, 
disappears at the end of one or two years. In rare cases all elec- 
trical irritability disappears from the onset. In others the faradio 
irritability in certain fibres and muscles returns after from six to 
twelve months. These muscles may partially recover, but remain 
atrophied and weak. There is usually no loss of sensation, but if 
it does occur, there is incontinence of urine. Reflex at the patellar 
tendon is lost and myotonic irritability is either lost or diminished. 
In cervical disease of the cord, or when only the posterior tibial mus- 
cle, or the muscles of the feet are paralyzed, the tendon reflex at the 
knee is present. In rare cases, the inflammation may spread from 
the anterior horns to the lateral columns. The lower extremities 
may then be paralyzed but not atrophied, and clonus may be present. 

Growth of bone is retarded, and one foot may after a time become 
shorter than the other. The joints become the seat of subluxations 
through the laxity of the muscle and lack of support. The articular 
ends of the bones are not held in apposition. Through the shorten- 
ing of some muscles and the traction of others there will result 
various forms of talipes. The muscles in front of the tibia are 
affected more than those of the calf. The extensors of the thigh are 
more frequently paralyzed than the flexors. 

The muscles of the whole arm may be paralyzed, or, as in Erb's 
paralysis, only those of the deltoid group. The serratus, the pecto- 
ralis, the muscles of the back and neck, and the diaphragm may 
all be affected. 

Course. — The mildest cases rarely make a complete recovery. 
Death is very uncommon and occurs only in the early stages. It 
may supervene within two weeks from general paralysis or cerebral 
disturbance. Relapses are rare, second attacks unknown. 

Sequelae. — A cord which has once been the seat of this disease 
is naturally susceptible. Gowers states that he has seen chronic 
disease of the cord supervene later in life. Progressive muscular 
atrophy or lateral sclerosis may at some later time appear in the cord. 

The prognosis of acute atrophic paralysis is good as to life. As 
to the outcome of the paralysis, a prediction can be made only when 
all the muscles which show faradic irritability have recovered. Some 
children who in the second stage have shown complete paresis or 
paralysis from the cervical region down, gradually regain power 
in all of the affected muscles, only one limb or part of a limb being 



826 DISEASES OF THE NERVOUS SYSTEM. 

permanently affected. As a rule those parts, which after a week 
respond to faradism, will recover. 

Diagnosis. — At the onset, the case should be distinguished from 
one of the infectious diseases. Since the mode of onset is much the 
same, it is best, as in those diseases, to defer making the diagnosis until 
the initial symptoms have passed and the paralysis appears. When 
the paralysis is fully developed, it should be differentiated from forms 
of cerebral palsy. This in the majority of cases is difficult. The 
characteristic atrophy, the complete paralysis, the loss of knee- 
jerk, and the absence of contractures will all be of service. Those 
cases in which pain in the course of the nerves is present at the 
onset, should be distinguished from cases of multiple peripheral 
neuritis. Time and study of the cases will make this possible. In 
those forms of poliomyelitis in young infants, in which the muscles 
of the deltoid group are affected, Erb's traumatic form of shoulder 
paralysis should be excluded. Some cases closely resemble this 
form of paralysis. If the paralysis occurs immediately after birth 
and follows traction on the arms, poliomyelitis may be excluded. 
If the paralysis occurs after the sixth month, the diagnosis, in the 
absence of any traumatic history, should be that of poliomyelitis. 

Morbid Anatomy. — The theory of Charcot, that anterior polio- 
myelitis is a primary degeneration of the ganglion-cells in the 
anterior horns of the gray matter in the cord, has given way to the 
belief that there is severe inflammation superinduced by some toxic 
agent circulating in the blood. The change begins in a degenera- 
tion of the bloodvessels of the anterior median fissure. There is 
proliferation of tlie endothelial lining of these vessels. The in- 
flammatory process extends to the surrounding neuroglia and 
the ganglion-cells supplied by those vessels in the anterior horns of 
gray matter. In severe cases, the motor nuclei of the medulla may 
be involved. There may be inflammatory exudation and hemor- 
rhage. In recent cases, the ganglion-cells show granular swelling, 
vacuole formation, hyaline changes, disintegration, and atrophy. 
After months, there is paucity of ganglion-cells in the region corre- 
sponding to the paralyzed members. They are seen in a few groups 
in the anterior horns or may be entirely wanting. Outside of the 
affected area, there may be a diminution of the number of ganglion- 
cells throughout the whole cord. The nerve-fibres corresponding to 
the ganglion-cells which have disappeared are also wanting. There 
may be no marked change in the glia tissue, in the transverse section 
of the anterior horns, and in the general configuration of the trans- 
verse section of the cord. After a time, however, there will be 
sclerosis and atrophy of the affected horn. The sclerosis may affect 
the white columns. The anterior horns and corresponding white 
substance may be transformed into a glia tissue resembling gelatin, 
the spaces containing fluid granules and disintegrated nerve-tissue 



FACIOSCAPULO HUMERAL FORM OF MUSCULAR ATROPHY. 827 

(Ziegler). All these changes point to permanent injury to the spino- 
muscular neuron, the ganglion-cell of the anterior horn, and its 
nerve-fibre. 

The treatment of anterior poliomyelitis is symptomatic. In 
the stage of onset, perfect rest and quiet are indicated, and a few 
remedies to meet the symptoms. The bowels are kept open with 
calomel. Bromides are used if the patient is restless. Ice applied 
to the nape of the neck or to the head, as in cerebral disease, is 
useful if there are cerebral symptoms, such as headaches. Ergot 
has been given to act on the blood-supply of the cord, but is 
of doubtful value. After paralysis is established and atrophy has 
made its appearance, massage of the affected muscles, and electricity, 
especially of the galvanic form, are indicated. Later, in the chronic 
stage, much can be done for the sufferers by orthopedic appliances, 
such as braces and splints. If there is contraction of opposing 
muscles, tenotomy should be resorted to. In cases in which the 
joints have become the seat of luxation, arthrodesis has been prac- 
tised by surgeons with good results in increasing the power of the 
affected limbs. 



THE JUVENILE FORM OF PROGRESSIVE MUSCULAR 
ATROPHY (ERB'S TYPE). 

This disease is characterized by a weakness and progressive 
wasting of certain muscles. It })egins in childhood or early youth, 
and involves, as a rule, the shoulder-girdle, the upper arm and pelvic 
girdle, and the thigh and back. The muscles of the forearm and leg 
remain for a time intact. This atrophy may be associated with true 
hypertrophy or pseudohypertrophy of some muscle. The pectoralis, 
the trapezii, the latissimi dorsi, the serrati, the rhomboids, the 
upper arm muscles and supraspinators, are apt to be wasted. The 
deltoids, supraspinati, and infraspinati may be normal or hyper- 
trophied for a time. There are no fibrillar contractions, no dis- 
turbances of sensation, and no reactions of degeneration and visceral 
disturbances. 



THE LANDOUZY OR DEJERINE TYPE OF THE FACIO- 
SCAPULO HUMERAL FORM OF MUSCULAR ATROPHY. 

This form in no way differs clinically or pathologically from the 
juvenile form of muscular atrophy. Authors include in this class 
all cases in which the atrophy begins in early life, as a rule, in the 
muscles of the face. The patients have a peculiar expression — 
so-called '^ facies myopathique." The lips are thickened (" bouche 



828 DISEASES OF THE NERVOUS SYSTEM. 

de tapir '' or tapir mouth). The shoulders later become atrophied. 
The supraspinati, infraspinati, and the flexors of the hands and fin- 
gers remain normal, as do the muscles of deglutition, mastication, res- 
piration, and the laryngeal and ocular muscles. There are no fibril- 
lary twitchings. The spinal forms of progressive muscular atrophy 
differ from primary dystrophy in that the onset of the latter affec- 
tion is in the upper extremities. The disease is not hereditary, and 
fibrillary twitchings and electrical reactions of degeneration are 
absent. 

Both these forms are probably clinical varieties of the pseudo- 
hypertrophic form of paralysis. 



PSEUDOHYPERTROPHIC MUSCULAR PARALYSIS. 

This disease is characterized by a progressive change in the size 
of many of the muscles of the body and by a diminution of their 
power. It was described by Duchenne in 1861. Since then the most 
notable work on the subject has been done by Gowers, of England, 
and Sachs, of this country. The male sex is more frequently af- 
fected than the female. From two to eight members of the same 
family are often affected. Isolated cases are uncommon. The dis- 
ease frequently affects the members of one sex in a family group. 
It is congenital but not hereditary. The antecedent cases, if there 
are sach, can usually be traced on the mother^s side of the family. 
The mother may be herself unaffected. Intemperance does not seem 
to exert any influence on the occurrence. Gowers notes that frequent 
marriage of parties closely related tends to predispose to the develop- 
ment of the disease in the children. In one-third of the cases the 
disease appears when the child begins to walk, and in children who 
are late in learning. It may manifest itself in the mid-period of 
childhood. In another third of the cases the children are in ap- 
parently good health until the fourth or sixth year. Three-fourths 
of the cases show symptoms of the disease before the tenth year. 
The disease may not manifest itself until after puberty, and may 
only be noticed during convalescence from some intercurrent acute 
disease. 

The symptoms are impairment of power and change in the form 
of groups of muscles or of single muscles. The impairment of 
power is at first not very apparent. The muscles of the calves 
enlarge, and show a very characteristic and significant hypertrophy. 
Mothers are at first pleased with what appears to be muscular 
development of the children (Gowers). It is then noticed that 
although the muscles of the calves and glutei are large, the children 
are easily fatigued in mounting stairs. They fall easily and rise 



PLATE XXXIII. 




Pseudohypertrophic Paralysis in a Boy Eight Years of Age. 
Hypertrophy of the infraspinati ^^^eIl shown; also atrophy of 
the muscles of the thorax and hypertrophy of the glutei and 
the muscles of the lower extremity. 



PSEUDOHYPERTROPHIC MUSCULAR PARALYSIS. 829 

with difficulty. This loss of power is at first interpreted as weak- 
ness, but when it is found to be progressive the children are brought 
to the physician. The gait becomes pronouncedly oscillating. The 
body is inclined so that the centre of gravity is brought successively 
over each foot. In trying to rise from the ground the patient places 
a hand on each knee in a very characteristic fashion. By grasping the 
thighs and throwing back the w^eight of the trunk, the patient helps 
himself into the erect posture. The weakness of the muscles finally 
becomes extreme. The patients can neither stand, walk, nor sit 
upright. They become bedridden. In the early stage, the muscles 
of the trunk may be normal, small, or atrophied, and those of the 
lower extremities much enlarged. Single muscles or groups of 
muscles of the arm and forearm may be enlarged (Plate XXXIIL). 
Finally, as the atrophy and weakness increase, there are contractures 
and distortions of the extremities and trunk. Equinus, lordosis, and 
lateral curvature are very marked. The knee may become fixed and 
distorted by contractures. The muscles most frequently affected in 
the beginning are those of the calves of the legs. These sometimes 
attain an enormous size. Those of the anterior part of the leg are 
not so much enlarged. The flexors of the knee commonly escape. 
The glutei and lumbar muscles are enlarged. The infraspinatus 
muscle is frequently enlarged, and stands out prominently ; it is often 
mistaken for the lower edge of the scapula. The deltoid is often 
large ; the serratus and the pectoralis are rarely affected. The triceps 
and biceps are frequently large, but often only in parts. The muscles 
of the forearm suffer only in a minority of cases. The intrinsic 
muscles of the hand are never affected. In that respect the disease 
is sharply distinguished from atrophies of spinal origin. The muscles 
of the neck are, with the exception of the clavicular portion of the 
sternomastoid, rarely affected. All the muscles affected are w^eak- 
ened, the smaller and atrophied muscles more so than the others. 
There is reason to believe that many muscles not visible are much 
affected. 

Electrical Reaction. — This is altered when weakness sets in. The 
electrical contractility to galvanic and faradic stimulus finally dis- 
appears. 

Reflexes. — The knee-jerk is at first normal. It later diminishes 
and finally disappears. It is never increased in a pure case. In one 
case in my hospital service there were increased reflex at the knee 
and foot-clonus. This case gave a history of a blow across the back. 
Sachs, witli whom I saw the case, suspected a complicating myelitis 
of the cord. 

Sensation is unaffected and the sphincters remain normal. 

The course of the affection is prolonged and tedious. The 
disease is progressive. It may be ten or fourteen years before the 
patients succumb. They die of some intercurrent disease. If the 



830 DISEASES OF THE NERVOUS SYSTEM. 

disease appears after puberty, the course is slower than in cases in 
which the first symptoms are noted in early childhood. 

Varieties. — There are cases in which only one muscle or group 
of muscles of the extremities is enlarged, the others being small or 
normal in size. There are other cases in which all the muscles are 
small and waste progressively. 

Complications. — Chorea, poliomyelitis, myelitis, mental deficien- 
cies, and epilepsy may complicate the affection. 

Morbid Anatomy. — The gray matter of the cord and the nerves 
are normal in appearance. There may be slight hemorrhages. The 
neuroglia-cells have sometimes been found to be increased. The 
disease is, however, primarily one of the muscle-tissue. The muscles 
are pale-yellow. They are replaced mainly by fat and connective 
tissue. The muscle-fibre is narrower than is normal, although in 
advanced cases the residual muscle-fibre may retain its transverse 
striation. Where the muscle-fibre is narrow it becomes granular 
or is the seat of fatty or waxy degeneration and vacuolization. 
Empty sarcolem ma-sheaths are seen. 

The diagnosis is made from the progressive weakness, the gait, 
and the mode of rising from the recumbent position. The peculiar 
enlargement of the muscles of the calf and infraspinatus, the atrophy 
of the latissimus dorsi and lower part of the pectoralis, and the 
immunity of the intrinsic muscles of the hand are characteristic. In 
the stage of contracture, this disease differs from congenital spastic 
paraplegia in that there is no increase of deep reflexes. 

The prognosis in children is grave. The affection is pro- 
gress iv^e. 

Treatment. — Much can be done for the patients by means of 
massage and electricity. In the stage of contractures, while there 
is still power, relief can be secured by tenotomy. 



DEFORMITIES OF THE SKULL AND SPINAL CANAL. 

These deformities do not strictly belong to the diseases of infancy 
and childhood. Only the forms most commonly met are here con- 
sidered. 

The faulty closure of the spinal canal causes a deformity called 
rachischisis or spina bifida. If the defect involves the spinal canal 
in its whole extent, there is rachischisis totalis. The vertebrae form 
a shallow canal in which lies the rudimentary spinal cord covered 
with a thin membrane. If the defect of the bony canal is only 
partial, there being a sac-like protrusion of the cord and its mem- 
brane, there is said to be a rachischisis cystica or spina bifida cystica 
or rachicele. 

Faulty development of the cranial bones with rudimentary brain 



SPINA BIFIDA. 



831 



is called cranioscliisis (Fig. 180). If with the cranial defects there 
are defects of the bony vertebral canal, there is said to be cranio- 
rachischisis. 

If there are only partial defects m the cranial bones, with saccu- 
lated protrusion of the membranes of the brain (pia and arachnoid), 
with fluid in the sac, there is a meningocele. Meningo-encephalocele 



Fig. 180. 




Cranioschisis. Deficiency of the frontal, parietal, and most of the occipital bones. Pro- 
trusion of the cranial contents in shape of a sac covered by hair and scalp, and containing 
fluid and brain substance. Blindness ; idiocy. 

is a sac containing in addition the brain-substance. Encephalocele 
is a hernia of the brain and pia, no fluid being present in the sac. 

Spina Bifida. 

Spina bifida or hydrorrhachis is a congenital deficiency in the ver- 
tebral laminae, through which the cord and its membranes protrude 
in the form of a sac containing fluid. The deformity is most fre- 
quently seen in the dorsolumbar, dorsosacral, and cervical portions 
of the vertebral canal. It rarely occurs in the middorsal region. It 
is generally single. It may occur both in the neck and in the 
lumbar region. 

The tumor may be small and only indicated by a fissure, or may, 
as in Broca's case, attain a circumference of 62 cm. It may be flat 
or peduncidated. The latter form is uncommon. The surface of 
the tumor may be smooth or lobulated and uneven. The lobulated 
forms indicate divisions in the interior of the sac. The skin covering 



832 DISEASES OF THE NERVOUS SYSTE3I. 

the sac may be very thin or glistening. It may burst daring delivery, 
may be thick and vascular, or covered with cicatrices and granu- 
latinoj ulcers. In some tumors the subcutaneous tissue can be made 
out ; in others the skin is atrophic. In rare cases the tumor is com- 
posed of a mass of mucous tissue situated between the skin and 
dura mater. In the interior of this mass there is a small cavity 
(Kirmisson). Von Recklinghausen and Muscatello have demon- 
strated that the statement that the sac of the spina bifida is lined with 
dura mater is incorrect. Hildebrandt has, however, found cases in 
which the dura lined the sac. The pia and arachnoid line the sac. 
The fluid in the sac is serous and colorless or lemon-colored. It is 
alkaline in reaction, rich in salts, and contains sugar. If inflam- 
mation is present, blood is found in the sac. The fluid is either 
outside the cord or in the central canal (Virchow). 

Spina bifida is, with reference to the nature of the contents of the 
sac, divided into three forms : 

(a) Myelomeningocele, in which the fluid in the sac is situated 
between the cord and its membranes. 

(6) Meningocele spinalis, in which the inner surface of the sac 
is formed by the arachnoid and pia mater. 

(c) Myelocystocele, in which the fluid is situated in the central 
canal of the cord. 

The myelomeningocele forms a broad but not very prominent 
tumor, which may be found in the lumbosacral, cervical, thoracic, or 
sacral regions. At its base the tumor is reddish, and is covered 
with fine, long hairs. This zone is from 1 to IJ cm. broad. In 
the centre of the tumor there is a reddish-brown velvety vascular 
area, the remains of the medullary vascular zone. The sac is formed 
of arachnoid and pia mater. Its interior is crossed by nerve-trunks. 
The cord is drawn outward and some nerves may arise from the pro- 
longations of the cord. Accordingly, there is an accumulation of 
fluid in the meninges (hydromeningocele), with an accompanying 
hernia of the cord (myelocele). 

Meningocele spinalis is the rarest form of spina bifida. The sac 
is composed of pia and arachnoid. The latter may be much thick- 
ened. The opening into the vertebral canal if large may allow hernia 
of the cord. If the tumor is situated in the sacral region, the interior 
of the sac may contain the nerves of cauda equina. 

Myelocystocele, hydromyelocele, or syringomyelocele, is that form 
of spina bifida in which there is a dilatation of the central canal of 
the cord. The dura is lacking in the sac, which is lined with cylin- 
drical epithelium. The spinal cord in part of its extent may be 
found in the sac, or may be found on the exterior wall of the sac 
and end there. It may break up into several bundles. In the 
interior the spinal nerves form a series of loops with their convexi- 
ties posteriorly. They may return into the vertebral canal or may 



SPINA BIFIDA. 



833 



eud in the sac. Spina bifida is a primary agenesis. The growth of 
the sac is due to inflammatory processes. 

Symptoms. — Tlie tumor is the chief physical sign. It is situated 
in the median line or may be at one side. It is round or elliptical 
and covered with thinned or thickened skin (Figs. 181 and 182). 
In the centre of the myelocystocele is a depression which gives the 
tumor a tomato-like appearance. The tumor may be soft, hard, or 
fluctuating. The defective vertebral laminae may be discerned on 
palpation. The tumor enlarges and becomes tense when the patient 
assumes the upright posture, cries, or exerts himself. When the 



Fig. 181. 



Fig. 182. 





Spherical form of spina bifida lumbalis. 



Elliptical form of spina bifida, with fistulous 
opening (o) into the vertebral canal. 



patient takes the recumbent posture it becomes smaller. It also does 
so at each inspiration. 

In some cases the functions of the individual are normal. In 
others, the mobility and sensibility of the lower extremities are 
aifected. Deformities of the foot similar to those seen in infantile 
paralysis are sometimes present. There may be incontinence of 
urine and feces. There are sometimes trophic disturbances, such as 
perforating ulcers. These are of value in the diagnosis of lumbar 
tumors which are apparently lipomatous in their nature and are 
covered with hair (Kirmisson). In such tumors, disturbances of 
sensibility occurring with perforating ulcers and deformity and 
atrophy of a lower extremity are significant of spina bifida. 

Course. — Spina bifida if left to itself may grow to a large size, 
may burst or ulcerate, and cause death by pyogenic infection of the 

53 



834 



DISEASES OF THE NERVOUS SYSTEM. 



meninges and cord tissue. In other cases a lineal ulcer discharges 
fluid and closes up several times in succession. In some cases of 
spina bifida the tumors remain stationary in size until late in adult 
life. In rare cases spontaneous cure results by inflammation of the 
pedicle of a pedunculated spina biflda. 

The diagnosis of spina biflda is not diflicult if what has been 
detailed of the anatomy and symptomatology is borne in mind. 
Muscatello gives the following characteristics of the various forms : 



Fig. 183. 



Fig. 184. 





Spina bifida lumbalis, with pes valgus on 
tlie right side ; also congenital subluxation 
of the hip. 



Spina bifida occulta pes calcaneovalguc 
on the right side ; pes equinovarus on the 
left side.i 



In myelocystocele there is a rouud tumor with a wide base. The 
tumor is lumbosacral, elastic, translucent, and fluctuating, and does 
not diminish on pressure. Pressure causes tenseness of the fonta- 
nelle. There may be scoliosis, lordosis, abdominovesical fissure, 
and deformity of the foot. 

In myelomeningocele there is a flat, soft, elastic tumor, either 
lumbar, sacral, cervical, or thoracic. It may be complicated by 



' Figs. 181-184 are taken from Kiruiisson. 



SPINA BIFIDA. 835 

umbilical hernia, paralysis of the extremities and bladder, and de- 
formity of the foot. 

In meningocele there is a sacral pedunculated translucent tumor, 
but no disturl)ances of mobility or sensibility. 

Of considerable interest is the form called spina bifida occulta 
(Fig. 184). In these cases there may be no tumor, the seat of 
the deformity being indicated by a depression or dimple. In other 
cases, as in that shown in the illustration from Kirmisson, there 
is a small tumor of doughy consistence on one of the gluteal folds. 
The tumor may present an umbilication. Spina bifida occulta should 
be suspected in cases in which abnormal sacral depressions or 
tumors occur in connection with clubfoot deformities or congenital 
incontinence of urine or feces, or of both. 

The treatment of spina bifida belongs to the domain of surgery. 
The treatment by injections of Morton's fluid (2 per cent, of iodine, 
6 per cent, of potassium iodide in glycerin) has been abandoned in 
favor of excision of the sac. 

References of Authorities for Collateral Reading. 

Bottze, Oito : Zur operativen Behandl. des Hydroceph. Chr., Thesis, Halle, 1893. 

Crozer Griffith, J. P.: "Tetany in America," American Journal Medical 
Sciences, 1895. 

Griffith: Hereditary Ataxia, Amer, Jour. Medical Sc, 1889. 

Epstein, A. : " Kataleptische Erscheinungen," Prag. med. Wochen., 1896. 

Escherich, T: : "Tetanic im Kindesalter," Berlin, klin. Wochen., 1897. 

Fischl, R. : ''Tetanic, Laryngospasmus u. Kachitis," Verhandl. d. Ges. f. 
Kinder., xiii. 

Bochsinger, C. : Myotonic der Sanglinge Wien, 1900. 

Hirsch, Wm. : "Pathological Anatomy of Amaurotic Family Idiocy," Journal 
Nervous and Mental Disease, 1898. 

Ireland, Wm. W. : The Mental Affections of Children, Philadelphia, 1900. 

Kirmisson, E. : Lehrbuch Ohirurg. Erkrank., Stuttgart, 1899. 

Macewen, Wm. : Pyogenic Infectious Diseases of Brain and Spinal Cord, 1893. 

McNutt, S. : '' Apoplexia Neonatorum," Amer. Jour. Obstet., etc., 1885. 

Olser, Wm.: Chorea, Philadelphia, 1894. 

Pfaundler, M. : "Lumbal pun ction," Beitrag zur klin. Med. u. Chir., Heft 20, 
1899. 

RotcK T. M. ; ''Rhachischisis," Trans. Amer. Ped. Soc, 1900. 

Riitimeyer : Virch. Arch., Bd. 90. 

Sachs, B. : Nervous Diseases of Children, New York, 1895. 

Sachs, B. : " Amaurotic Idiocy," Deutsch. med. Woch., 1898. 

Sdenger, A. : Neurasthenic u. Hysteric bei Kindern, Berlin, 1902. 

Thomson, J.: "Infantile Respiratory Spasm," Edinburgh Medical Journal, 
1892. 

"Congenital Stridor," British Medical Journal, 1900. 



SECTION XIV. 

DISEASES OF THE SKIN. 

The skin of the infant is exceedingly delicate in structure. After 
birth there is a physiological condition of desquamation, as a result 
of which the skin is very sensitive to a traumatism which in older 
children would be considered slight. In the newly born infant, such 
is the delicacy of the structure of the skin that infection may occur 
when no lesion of continuity is apparent (cryptogenic). A rapid 
examination of the skin is the first step in making a full physical 
examination of an infant or child. The surface is first inspected 
from a distance, the color and the presence or absence of an eruption 
being noted. It is of the first importance to decide whether an 
eruption is acute or connected with constitutional taint (syphilis). 
An eczema may in a syphilitic infant have certain characteristic 
variations of color which will at once lead the examiner to suspect 
constitutional disease. A familiarity with acute eruptions (exan- 
thematic) is essential. These must be diagnosed or excluded before 
any treatment can be inaugurated. Forms of oedema must be differ- 
entiated from sclerema and myxoedema, and indurations of the skin 
from elevations. A papule may be elevated but not indurated. 
Since the skin of infants and children is exceedingly delicate, it will 
show indurations more distinctly than that of the adult. 

The Care of the Skin. — Stretching or harsh manipulation of the 
skin of infants will tear or traumatize it. Irritating soaps should 
not be used. The drying of the skin should be carried out gently. 
The skin in the groin and axilla should not be unduly stretched lest 
rhagades or fissures result. In powdering the skin, a fresh pledget 
of absorbent cotton should be used as a powder pufF, and all the 
excess of powder blown oif, lest caking result. In some infants the 
wearing of flannel or wool next to the skin causes irritation and 
eruptions of difl(erent varieties. Such infants should wear a very 
fine cambric or linen garment next the skin, and over this the 
woollen shirt. 

ECZEMA. 

Eczema is a very common affection in infancy and childhood. 

Some infants, otherwise in apparent health, suffer at times from 
a very mild eczema of the face, which appears chiefly on the cheeks, 
but which may also be present on the chin, forehead, and ears. The 

837 



838 DISEASES OF THE SKIN. 

infants do not seem to suffer much, except that they scratch the 
eruption. The eruption is local. It may improve without treat- 
ment, but if there are conditions of traumatism and infection, it will 
grow^ worse. It is rarely moist, but, if scratched, it will bleed, and 
fissures or ulcers with bloody crusts will form. 

Another form of eczema is pustular and vesicular. The skin of 
the face has a red, angry look. Here and there, patches of skin are 
covered with scabs ; in other areas the skin is moistened by a serous 
or seropurulent exudate. This eczema is usually also present on 
the hands and arms. If the malady has existed any length of time, 
there is considerable thickening of the skin of the hands. The head 
and scalp may be affected. 

Eczema is sometimes general. On the face, it is general and pus- 
tular ; on the body, there are both the squamous and the pustular forms 
with all the various gradations between. There are crusts, rhag- 
ades, and areas of superficial loss of tissue. 

The infants scratch and are uneasy and restless at night, but the 
general health is excellent and the appetite and digestion are good. 
The weight increases. If the eczema is general, the infants some- 
times become puny. They scratch the eruption, constantly causing 
the surface to bleed. The body is sometimes one raw, suppurating 
surface. The lymph-nodes connected with the affected surface are 
enlarged. Such enlargements should be differentiated from those of 
pyogenic origin. 

A very troublesome form of eczema is the impetiginous or pus- 
tular variety. The pustules burst and leave the surface covered with 
dried crusts of pus. This form may affect any part of the body. 
Of especial interest, and in a class apart, is the so-called impetigo 
faciei contagiosa. This is a contagious pustular eczema. It affects by 
predilection the upper lip and the alse nasi. The pustules break down 
and leave dry crusts of a golden-yellow color. The anterior nares 
may be blocked up by these crusts. This variety of impetigo may 
in children spread over the whole surface and the extremities. I 
have seen it affect several children in a family. There can be very 
little doubt as to the infectious and contagious nature of the malady. 
Eichstedt, Lustgarten, and others have, with cocci obtained from the 
pustules, succeeded in inoculating the malady on the human subject. 

Intertrigo (eczema intertrigo) or erythema intertrigo is one of the 
forms of erythema which develop by maceration into an eczema. 
Intertrigo is found in the folds of the neck, axilla, and groin, in 
well-nourished, rather obese infants. It is at first acute, but may 
become chronic. There is at first a slight redness of the folds of the 
skin (erythema). If through neglect the epidermis is allowed to macer- 
ate, excess of secretion results and the collected secretions decompose ; 
the surfaces may become eroded, and ulcerations result. In some 
cases there are lineal ulcers in the groin. In others, the ulcers may 



ECZEMA. 839 

become coated with a pseudomembrane. In rare cases actual 
necrosis of tissue results. Some anaemic infants present a ten- 
dency to rhagade formation, not only in the groin, but also around 
the anus and lips. The intertrigo may have the color of copper, 
instead of the bright-red hue of an ordinary eczema. In such cases 
there is always a possibility that the intertrigo may be of syphilitic 
origin. If there is no great pauniculus of fat, and if with the inter- 
trigo there appear erythema and fissures between the toes, and glossi- 
ness of the skin on the plantar surface of the feet, there are additional 
grounds for assuming that there is a syphilitic element. Intertrigo, 
like other skin eruptions, may be accompanied by enlargement of 
the lymph-nodes leading from the region affected. In obese infants, 
the umbilicus may also be the seat of eczema, which results from the 
accumulation and decomposition of secretions. 

Seborrhoea capillitii is an eruption on the scalp of infants and 
children, which is classified by Unna as a form of eczema. The scalp is 
covered with a coating of yellow or discolored sebum, which consists 
of fat, desquamated epithelium, and hair. If allowed to accumulate, 
it is sometimes of considerable thickness and may be detached from 
the scalp. It then leaves a slightly reddened surface, which may 
bleed. In a short time the scalp may become glossy, and a new 
layer of the fatty secretion may form. This process may continue 
until the second or third year. This seborrhoeic eczema has some- 
times a cheesy odor. 

Seborrhoea of the umbilicus has been mentioned. In infants and 
children there may also be seborrhoea of the prepuce. There are, 
in neglected cases, secretion and aphthous ulcerations of the folds 
between the glands and the prepuce and in the folds of the prepuce. 

Of great interest to the physician is a form of intertrigo or 
eczema found on the buttocks and between the nates of infants. It 
occurs in infants who are not kept dry and whose urine decomposes 
easily if the diapers are not changed frequently. This is a most 
troublesome form of eczema. The nates are at first red, the skin 
then becomes glossy and brittle, and there may be extensive desqua- 
mation of the surface. This form of eczema or intertrigo may dis- 
appear under treatment, only to return if precautions as to clean- 
liness and dryness are not observed. Some of the children suffer 
from enuresis, and contract the affection through maceration of the 
skin by the decomposed urine, or from unclean diapers. 

The etiology of eczema is still obscure. The conditions in 
infancy and childhood are favorable to the development of skin 
affections. The delicacy of the skin, its constant exposure to 
dirt and to irritants of all kinds, and changes of temperature, are 
etiologically important. All the children of a family may suffer 
from eczema. In such instances, there is a real hereditary ten- 
dency to the disease. The parents are sometimes similarly affected. 



840 DISEASES OF THE SKIN. 

The influence of diet in causing eczema is not yet understood, but 
some authors are firmly convinced of the deleterious effects of 
certain articles of food. I have known urticaria to be caused by 
eating oatmeal and fruits, such as strawberries, and urticaria may 
be the beginning of eczema. In most cases eczema cannot be 
attributed to articles of diet. It is possible that in certain children 
the processes of metabolism are at fault. Though it has not been 
proved that all eczema is of an infectious character, there can be 
but little doubt that many forms are caused by the deleterious action 
of micro-organisms on the skin (Unna). In favor of this theory is 
the fact that in many parasitic skin aifections eczema is an accom- 
panying condition. 

The treatment of eczema is exceedingly difficult. The external 
causes of irritation should be immediately removed. Attention to 
cleanliness is alone sometimes sufficient to cure an eczema. If 
woollen clothing is irritating to the skin, a substitute should be 
found and cotton or cambric should be worn underneath the w^ool. 

The diet should be regulated. This is not an easy task, since 
it is not known what articles of diet produce eczema. If the 
infant is at the breast, the diet of the wet-nurse and her daily habits 
should be regulated. Even when the nurse takes simple food, and 
the milk is flawless, the infant may suffer from eczema. If the 
nurse is addicted to the use of beer, or vegetables, such as asparagus, 
the quality of the milk may be affected. The diet of a wet-nurse 
should not be changed more often than is necessary, else the secretion 
of milk may cease. If the wet-nurse has a rheumatic or gouty ten- 
dency, it is wise to change nurses. On the other hand, an infant may 
be overfed and excessively fat. In that case the intervals between 
nursing should be lengthened. To attempt to change the percentage 
of fat in the milk is not only of questionable utility, but is not always 
feasible. If the nurse is constipated, the bowels should be regulated, 
and she should take abundant exercise. Artifically fed infants are 
still more difficult to manage. If the infant is thriving, interference 
with the food percentage is not always clearly indicated. Artificially 
fed infants may also be overfed or the percentage of fat or proteids 
may be too high. There may, however, be eczema even when the 
composition of milk is proper for the infant, age and weight being 
taken into consideration. 

If there are acidity of the stomach, excessive flatus, constipation, 
or green stools, regulation of diet is of more practical utility. In 
such cases it may cause the eczema to diminish. If there is stomach 
acidity, an alkali (lime-water) should be added to the food. Consti- 
pation and flatulence should be remedied. If the infant passes urine 
loaded with urates to such an extent as to cause a red deposit on 
the diaper, small doses of bicarbonate of sodium should be adminis- 
tered and lime-water should be mixed with the food. 



ECZEMA. 841 

Changes of diet are helpful only in those forms of eczema which 
are either general or disseminated over different parts of the surface. 
Seborrhoea and intertrigo are purely local affections, and are not 
influenced by changes of diet. 

Local treatment is chiefly relied upon to improve the condition 
of the skin. In the acute or subacute forms soothing applications 
are utilized. The chronic forms are irritated into a state of reaction, 
and then treated like acute eczema. The treatment of acute local 
eruptions, such as intertrigo, consists first in keeping the parts scru- 
pulously clean. After the bath the folds of the skin are mopped, 
dried carefully, and powdered, the excess of powder being blown 
off. This alone is sometimes sufficient to cure a slight intertrigo. 
Dusting-powders which contain carbolized preparations irritate the 
skin. A good powder has the following composition : 

K: Zinci oxidi ^iv (16.0). 

Amylum 5ij (60.0).— M. 

Equal parts of zinc and starch powder make an equally good powder. 
These ingredients should be ground to an impalpable powder. In 
the severer forms of intertrigo, the parts should first be anointed with 
ointment having the following composition : 

E Kesorcin . gr. ij-iv (0.12-0.24). 

Adeps benzoinati ^j (30.0). 

M. — The lard should be washed. 

The ointment should be removed from the folds of the skin with 
a pledget of lint. The skin after being thus left in a slightly 
greasy state is powdered, the excess of powder being blown off. If 
there are lineal ulcers in the groin, they should be lightly touched 
once a day with a 2 per cent, solution of nitrate of silver, to promote 
granulation. The ointment should then be applied with a small 
piece of lint. 

In squamous eczema, which is a red or pustular eczema of the face, 
scalp, and hands, the first question that arises is whether the patients 
should be bathed. An infant should be kept clean, and there is only 
one satisfactory method, and that is the bath. If there is eczema of 
any part of the surface, the bath water may be liberally impregnated 
with bran. A gauze bag filled with a measure of bran is put into 
the bath and the bag squeezed until the water becomes turbid. If 
a minute quantity of bicarbonate of sodium is added to a bath pre- 
pared in this way, the effect on general eczema is decidedly soothing. 
The skin is gently dried after the bath and powdered. If the whole 
trunk is involved, it is best that the parts of the surface should be 
treated in succession. The face or an arm is covered with an oint- 
ment applied by means of a piece of lint, or the ointment is simply 
rubbed on the skin after the bath. It is not feasible to wrap the 
whole body in lint and ointment ; with certain drugs, such as 



842 DISEASES OF THE SKIN. 

resorcin, absorption would occur. The ointments should be applied 
after the crusts and pustular accumulations have been removed. All 
ointments should be made up with washed benzoinated lard. Vaseline 
is very irritating to some forms of eczema. Of the emollient and 
soothing ointments, diachylon, zinc, and bismuth hold a leading 
place. A very good ointment for general use in rhagades and 
squamous eczema is the following, which is one of Kaposi's formulae : 

li Resin, benzoea pulv 3j (4.0). 

Axung. pore ^v (150.0). 

Digere cola adde. 

Zinc.oxidat ^j (30.0). 

M. et. ft. unguentum. 

If made up properly, this is an excellent cosmetic ointment for use 
in dry eczema. If the skin is dry and thickened, a 1 per cent. 
/?-napthol applied twice daily will soften it. If this treatment proves 
irritating, a zinc ointment may be applied immediately afterward. 
In many cases of chronic eczema Lassar's paste is beneficial : 

Ut Acidisalicyl gr. xxx (2.0). 

Zinci oxidat. ) -- s- /oAn\ 

. 1 / aa .=^1 (30.0). 

Amylum / oj \ > 

Vaselin ^jss (45.0). 

M. et ft. paste. 

The following ointment is also excellent : 

R Acidi salicylic! gr. xv (1.0). 

Ung. zinci oxidi Jij (60.0). — M. 

The tar salves and mixtures are useful in cases of chronic eczema 
in which there is little or no moisture. 

R 01. rusci 3J (4.0). 

Ungt. zinci ox ^j (30.0). 

M. — For external use. 

or 

R 01. fagi SiJss (10.0). 

Glycerin .^j (4.0). 

Ung. diachylon ,^jss (45.0). 

Balsam. Peru 1^ xxx (2.0).— M. 

In cases of red eczema of the face, the ointment is best applied 
on a mask made of lint. 

In that form of intertrigo which results from the irritation of 
urine, the condition of the diaper is frequently the chief source of 
trouble. It is often damp or too thin. As a result, Avhenever the 
infant passes urine, the diaper becomes saturated with it and decom- 
position takes place. A piece of absorbent gauze as large as the 
diaper should be placed next the skin, and renewed whenever it 
becomes moistened. The skin is dried and the ointment applied on 
the gauze. Intertrigo is quickly cured by this treatment. 



ERYTHEMA MULTIFORME. 843 

Treatment of Seborrhoea of the Scalp. 

The accumulated sebum is moistened with oil, or a piece of 
lint moistened with olive oil or any indifferent oil is applied at 
night. In the morning the crust of sebum will have softened 
sufficiently to allow of its removal with green soap and water. 
After the parts are well cleaned, a salicylated ointment, 0.5 to 1 per 
cent., is applied daily. The ointment should be sparingly applied in 
order that it may not irritate the parts. Seborrhoea should be treated 
for some time after it is apparently cured, or it will return. In 
older children who have abundant hair, the seborrhoea accumulates 
at the roots and the scalp has an odor. The head should be thor- 
oughly shampooed once a week ; after the shampoo, an exceedingly 
small quantity of cosmetic hair oil should be applied to the scalp 
once a day. 

ERYTHEMA MULTIFORME. 

{Erythema Nodosum; Erythema Exudativum.) 

Erythema exudativum is divided into two forms. The acute 
form includes erytheuia multiforme and nodosum, and is an acute 
infectious disease (Lewin). The exudative form occurs frequently 
in infants and children. Of "40 of my cases, 10 were under two 
years of age. The form of erythema known as erythema nodosum 
begins with general malaise and sometimes with fever, which may 
be quite high. There is pain in the joints and over the areas affected. 
These areas are raised and are purple or bluish ; the skin is tense and 
the parts affected are very painful. The nodes vary in size. They 
first appear chiefly on the extensor surface of the tibiae. The 
extremity sometimes looks as if it had been beaten. This form 
of erythema is perhaps allied to hemorrhagic diseases, such as 
peliosis. In a case of peliosis rheumatica which I saw recently 
there were erythematous and painful nodules on the hands. Anti- 
toxin may cause exudative erythema. As is vv^ell known, such toxic 
infection also involves the joints. The symptoms are fever, pain in 
the joints, and extensive erythema nodosum. I have seen such a 
case in a subject, who had received an immunizing injection. Within 
six hours, the legs, knees, and thighs were swollen and the seat of 
this peculiar erythema. 

French writers speak of the frequency of cardiac disease in 
erythema nodosum, and of its relationship to rheumatism. I have 
carefully studied 40 cases for signs of cardiac disease, and could 
find only 3 cases with systolic murmur at the apex. I have recently 
seen 2 others. In my opinion, true endocarditis is not a very com- 
mon complication of erythema nodosum. In only one case did the 



844 DISEASES OF THE SKIN. 

murmurs appear to be serious. The disease lasts only a few days, 
but there may be relapses. 

The second form of chronic erythema resembles the acute form. 
The nodules are flat and deep, and are not raised much above the 
surface. They appear chiefly on the lower extremities of badly nour- 
ished children. They are less painful than in the acute form. After 
a time they disappear leaving no sign of their presence. 

Treatment. — Cases of erythema of the acute form are treated 
with sodium salicylate and a diet of milk at first, fruit-juices and beef- 
juice being given later, and local applications of oil of wintergreen 
to the painful areas. 

FURUNCULOSIS. 

{Folliculitis Abscedens or Perifolliculitis Abscedens. — Escherich.) 

This affection of the skin is very common in infancy and child- 
hood, and occurs chiefly in badly nourished, marantic babies, who 
suffer from gastro-enteric and pulmonary infections. The disease is 
due to an invasion of the deeper layers of the skin by staphylococci. 
These have been found in the pus and in the sweat and sebaceous 
glands of the skin (Escherich). In the mild forms of furunculosis 
there are one, two, or more furuncles on the forehead, scalp, occiput, 
and neck. Sometimes the furuncles are large and the skin is riddled 
with them, but as a rule they do not communicate with one another. 
In aggravated cases, furuncular abscesses occur on the trunk and on 
the upper and lower extremities. When the furuncles or boils 
become very numerous, they play a leading role. Many children in 
institutions succumb to this affection. The condition closely resem- 
bles a form of sepsis. 

The treatment of these cases is simple. I have administered 
alkalies, such as bicarbonate of sodium, internally. The effect on 
the general process is excellent. I have also given sulphide of cal- 
cium in grain J doses (0.03) with good effect. The infixnt is 
bathed in bran daily. Too many of the abscesses should not be 
opened at once, and they should not be opened until they point and 
the skin over tliem becomes reddened. If they are opened earlier, 
the results are not so good. After the abscesses are opened, the pus 
is expressed and a moist dressing applied. The abscesses heal easily. 
As in other septic affections, the patients should be stimulated and 
carefully fed. Small furuncles appearing only on the face need not 
be opened. The application of a 2 per cent, salicylated ointment 
twice daily softens the pustules and causes the contents to be dis- 
charged. 



DERMATITIS EXFOLIATIVA. 845 

SUDAMINA. 

{Miliaria Alba; Miliaria Rubra.) 

Sudamina is an affection occurring in infants and children during 
very warm weather. In the form called miliaria alba the epidermis 
at the openings of the sweat-glands is raised by a minute serous exu- 
date and small vesicles are formed. There is no inflammation of 
the skin. In a second form, the same process takes place, with the 
presence of a minute focus of inflammation and redness at the opening 
of the glands. Some of the vesicles are pustular. There are also 
numerous papules of eczema. There is a slight infection of the skin 
about the opening of the sw^eat-glands. Both these conditions 
are irritating, but in no way serious. The skin should be kept 
scrupulously clean and dried with powder. Woollen fabrics should 
not be worn next the skin. If the condition becomes severe, 
bran baths and a bland zinc or diachylon ointment should be 
used. Sudamina of both varieties are met with in scarlet fever 
dermatitis. 

DERMATITIS EXFOLIATIVA. 

(ElTTER VON KiTTERSHAIN.) 

This affection is peculiar to the newborn infant. Ritter in 1878 
described an epidemic. In 1895, Escherich published an account 
of a small local outbreak in Gratz. 

Nature and Etiology. — It was first suspected by Ritter to be 
one of the septic infections of the newly born infant. His view has 
lately been supported by Escherich. 

Occurrence and Symptoms. — The disease appears from a few 
days to two weeks after birth. It usually occurs in poorly nourished 
infants, but may affect apparently healthy infants of normal weight. 
Boys are more frequently affected than girls. The affection is pre- 
ceded by the appearance of a diffusely red erythematous or dark 
swelling of the general surface. The skin is thickened, soft, mac- 
erated, and velvety to the touch. The epidermis can be moved on 
the corium beneath. The pressure of the clothing or bedclothes may 
also produce this effect. Minute vesicles appear, and coalesce to 
form larger vesicles or bullae. Vesicles or bullae of large size which 
may be either partly filled with serum or empty are formed. They 
are never tense, and finally open or tear, leaving the red moist corium 
exposed. The surface of the body has a beefy-red color, and is 
covered here and there with patches of dry, adherent epidei-mis ; in 
other areas, the corium is exposed. There are rhagades at the angles 
of the mouth and on the trunk. The upper extremities become 
affected later than the lower ones. Whole areas of the trunk and 
body are denuded of epidermis. After the vesicles burst and leave 



846 DISEASES OF THE SKIN. 

the corium exposed, the epidermal layer of the skiu is still adherent 
in places, while the desquamated skin is rolled up into cord-like 
masses and hangs loosely exposed. If recovery takes place, the 
corium becomes covered with a delicate epidermis, which gradually 
assumes the normal pinkish-white hue. Some cases may run an 
afebrile, others, a febrile course. 

Course and Prognosis. — A few of the cases recover. Ritter 
lost 50 per cent, of his cases, and Escherich 90 per cent. The 
infants may die from the sixth to the tenth day or after the third 
week, when much of the skin has undergone retrograde changes. 
The cases may show umbilical infection or lobular pneumonia point- 
ing to the septic nature of the disease. 

Treatment. — The infants are kept warm by artificial means, 
such as warming bottles or an incubator. They are not bathed. The 
skin is protected by the application of bland salves or gauze moist- 
ened w^ith a mixture of linseed oil and lime-water (Escherich). 
Some physicians add a small quantity of salicylic acid to the salves. 
As soon as the skin has become dry, Lassar's paste and powdered 
zinc are applied. 



CONGENITAL ICHTHYOSIS. 

[Cutis Sebacea.) 

Ballantyne gives an exhaustive description of this affection, which 
is really a perpetuation of a foetal condition into post-natal life. 
The foetal skin has a tendency to seborrhoea. This is apparent after 
birth, and is evident during infancy as seborrhoea of the scalp. The 
seborrhoea may affect different parts of the body and may form thin 
shining scales on the surface of the skin. There may be secondary 
eczema. The mild forms may, with ordinary cleanliness and the appli- 
cation of bland salves, disappear a few weeks after birth. The form 
described by Hebra and Kaposi as ichthyosis congenita is an extreme 
example of the tendency of the foetal skin to the formation of sebum 
or vernix. The increased secretion continues after birth. The in- 
fant appears to be covered with a horny mass which almost envelops 
it. This parchment-like covering is absent at the mouth, eyes, anus, 
and on the scalp. The surface is firm and of a yellow or brownish- 
red tint (Escherich). The hardness and brittleness of the skin 
render motion painful. The infant is enclosed as if in case-armor. 
The face has a mask-like expression. The skin is broken in places, 
especially at the joints. At these fissures the true skin is seen. At 
the broken spots, the sebum is seen to be composed of lamellae, from 
the posterior aspect of which project warty excrescences corresponding 
to the lanugo and openings of the sebaceous glands. These may be 
removed from the skin. If the infant lives, the layers of sebum are 



PEMPHIGUS NEONATORUM. 847 

thrown off gradually, and the skin is left with a general seborrhoea 
of the ordinary type. Escherich predicts a favorable course in most 
of these cases, but some die shortly after birth. Pathologically there 
is a great thickening of the rete Malpighii ; the corium shows no 
changes ; the sebaceous glands are atrophied or the seat of fatty 
degeneration ; the sudoriparous glands are normal. After the layers 
of horny sebum have peeled off, the skin underneath appears pink or 
red or shining, and is covered with seborrhoea! scales. 

The treatment consists in the application of emollients and in 
washing the skin daily or bathing the infant in permanganate of 
potassium (grains xv (1.0) to the bath water). Salicylic and boric 
ointments are applied after the baths. 



PEMPHIGUS NEONATORUM. 

Pemphigus neonatorum is a contagious infectious disease of the 
skin occurring in the newborn infant. It has also been observed 
later in infancy. It usually appears at the end of the first or second 
week, and affects the whole surface, except the palms of the hands 
and the soles of the feet. There appear on the surface of the trunk 
and extremities small and large vesicles containing cloudy serum. 
These burst and leave a round patch of skin, which dries and is 
covered with yellowish scales. The vesicles may attain the size of 
bullae. They may be discrete or involve the whole body, so that 
the surface is after a time denuded of the epithelial layer. The 
disease may in the beginning be confounded with dermatitis exfoli- 
ativa. The vesicles may appear in crops ; the recurrences may 
extend over a period of from two to four weeks. 

There are two forms, in one of which the disease is mild ; in the 
other, it runs a malignant course, and from the outset large areas of 
skin are denuded of epithelium by the bursting of enormous bullae. 
The infants pass into an asthenic condition, refuse nourishment, and 
die in a few days. Both forms appear in epidemics. The disease 
occurs sporadically. The essential cause is still obscure. Strelitz, 
Demme, Almquist, and Escherich have isolated a white staphylo- 
coccus from the serum of the vesicles. Its role as an etiological 
factor is not as yet understood. Escherich is inclined to class this 
form of pemphigus with other infectious skin diseases, such as the 
impetigo of AYilson or Bockhart, and folliculitis abscedens, in which 
certain conditions favor serous infiltration of the horny layer of the 
skin and extensive desquamation from the corium. He believes the 
exciting cause to be the pus cocci found in other forms of impetigo. 
Eschericih has suggested the use of the name '' Impetigo Bullosa 
Neonatorum or Infantum '^ for this affection. 

The prognosis is favorable if the process confines itself to the 



848 DISEASES OF THE SKIN. 

superficial layers of the skin. If the deeper layers are attacked, 
abscesses and general sepsis result. 

Treatment. — Escherich recommends that the affected parts 
be washed with soap and water, and dressed with a 2 per cent, 
ointment of white precipitate. Baths are not given. Those who are 
interested in the epidemiological aspect of this disease will find the 
monograph of Richter exhaustive. 

References of Authorities for Collateral Reading. 

Ballantyne, J. W. : Antenatal Pathology and Hygiene, Edin., 1902. 

Escherich, T. : " Diseases of the Skin in the Newly Born," Pediatrics, 1897. 

" Zur aetiol. der Multiplan Abcesse. Folliculitis Abscedens," Miinch. 

med. Woch., 1886, Nos. 51 and 52. 

Richter, Paul: Ueber Pemphigus Neonatorum, Berlin, 1902. 

Unna, P. G.: Article "Eczem.," in Handbuch der Hautkrankheiten, Mrapek, 
1902. 



INDEX 



ABDOMEN, boat-shaped, in menin- 
gitis, 40 
in septic peritonitis, 41 
examination of, 40 
inspection of, 40 

in intestinal colic, 41 
in intussusception, 41 
in peritonits, 41 
for tumor, 41 
pain in, 41 
palpation of, 41 
Abdominal pain, 41 

in appendicitis, 41 
in pericarditis, 41 
in pleurisy, 41 
in pneumonia, 41 
in typhoid fever, 288 
tuberculosis, 389 
tumor, dyspnoea in, 564 
Abscess of brain in bronchiectasis, 558 
of breast, 118 
of liver, 519 

in bronchiectasis, 558 
as cause of peritonitis, 522 
of lung in bronchiectasis, 559 

in bronchopneumonia, 590 
mediastinal, in scarlet fever, 236 
perinephritic, differentiated from 

acute appendicitis, 504 
perioesophageal, 446 
periproctitic, 487 
retro-cesophageal, 446 
retropharyngeal, 534 

in acute follicular amygdalitis, 

539 
in diphtheria, 350 
inspiratory crowing in, 536 
skin, in cretinism, 692 

in scarlet fever, 238 
subphrenic, 622 
of thymus gland, 698 
Acetone breath in cyclic vomiting, 460 

in diabetes, 681 
Acetonuria, 31 
Achondroplasia, 675 
Acid intoxication, 479 
Addison's disease, 728 

melanodermie in, 728 
occurrence of, 728 
symptoms of, 728 
treatment of, 728 
Adenie, 715 

54 



Adenitis, acute, 686 

diagnosis of, 687 
etiology of, 686 
occurrence of, 686 
from parotid enlargement, 687 
symptoms of, 686 
treatment of, 687 
Adenoid tumors of imibilicus, 201 
vegetations, 533 

diagnosis of, 533 
methods of examination, 534 
treatment of, 534 
operative, 534 

contraindications, 534 
varieties of, 533 
Adenoids, examination for, 527 
Adenopathy, syphilitic, 685 
Air, open, 56 

protection of face in, 57 
sleeping in, 56 

wearing of short stockings in, 
57 
Albinism, nystagmus in, 37 
Albumin, digestion of, 451, 453 

in urine of newborn, 166 
Albuminuria, 31 
cyclic, 741 

differentiated from nephritis, 742 
occurrence of, 741 
postural, 741 
prognosis of, 742 
symptoms of, 742 
treatment of, 743 
in influenza, 307 
in measles, 267 
in mumps, 333 
in scarlet fever, 243 
Alexins in human milk, 17,79, 84 
Allenbury food, malted, 11] 
No. 1, 111 
No. 3, 111 
Amaurosis in measles, 268 

in scarlet fever, 244 
Amaurotic idiocy, 805 

idiots, position of head of, 35 

spasticity in, 47 
paralysis, position of head in, 35 
Amblyopia, infantile, 37 
nystagmus in, 37 
in typhoid fever, 290 
Amoebic dysentery, Charcot-Leyden crys- 
tals in, 489 

849 



850 



INDEX. 



Amygdalitis, acute, follicular, 538 

age of occurrence of, 538 
diagnosis of, 539 
duration of, 539 
endocarditis in, 539 
etiology of, 538 
nephritis in, 539 
otitis in, 539 
prognosis of, 539 
retropharyngeal abscess in, 

539 
rheumatic cases, 539 
symptoms of, 538 
treatment of, 540 
Amylase absent in cows' milk, 84 

in human milk, 84 
Amyloid kidney in bronchitis, 558 

liver in bronchiectasis, 558 
Amylolytic ferment in secretions of 
mouth, 423 
ferments in saliva of newborn, 161 
Ansemia, 705 

lymphatica, 715 
pernicious, 720 
blood in, 721 
characterist 
of rachitis, 669 
simple, 706 

blood in, 707 
symptoms of, 706 
Ansemic murmurs, 655 
Angina in influenza, 305 
in measles, 264 
membranous, 236 
in rotheln, 254 
in scarlet fever, 235 
Angiospastic cyanosis, 196 
Anomalies, congenital, 174 

hydrocele congenita, 175 
retentio testis, 174 
of scrotum, 174 
Anorchidisra, 174 
Antitoxins in human milk, 88 
Anus, absence of, in constipation, 489 
Assure of, 507 

constipation in, 491, 507 
diagnosis of, 507 
etiology of, 507 
symptoms of, 507 
in syphilitic babies, 507 
treatment of, 507 
prolapsus, 506 

etiology of, 506 
symptoms of, 506 
treatment of, 506 
spasms of, 507 
Aphasia in scarlet fever, 244 

in typhoid fever, 290 
Aphthae, Bednai-'s, 196, 424, 431 
Apnoea, expiratory, 786 

uterine, 157 
Apomorphine, 59 
Appendicitis, abdominal pain in, 41 



Appendicitis, acute, 501 
in children, 501 
course of, 502 
diagnosis of, 503 

from lobar pneumonia, 504 
from perinephritic abscess, 

504 
from tuberculosis perito- 
nitis, 504 
fever in, 504 
forms of, 501 

catarrhal, 501 

symptoms of, 501 
gangrenous, 502 

symptoms of, 502 
perforative, 502 

symptoms of, 502 
frequency of, 501 
McBurney's point in, 504 
and peritonitis, 522 
palpation in, 503 
percussion in, 504 
prognosis of, 504 
symptoms of, 501 
chronic, 505 

symptoms of, 505 
treatment of, 505 
Appendix, vermiform. See Vermiform 

appendix. 
Apthse differentiated from diphtheria, 356 
Argyll-Kobertson pupil in hereditary 

ataxia, 821 
Armour's beef-extract, composition of, 
108 ^ 
beef-juice, composition of, 106 
wine of peptone, 106 
Arrowroot gruel, ]05 

composition of, 105 
preparation of, 105 
Arterial murmurs, 656 
Arteries, umbilical, 159 
Arteritis umbilicalis. 202 
cause of, 202 
course of, 204 
pathology of, 202 
prognosis of, 204 
symptoms of, 203 
Hennig's, 204 
Arthritis, bronchopneumonia in, 590 
deformans, 673 
in dysentery, 487 
rheumatoid, 673 

definition of, 673 
lymph-nodes enlarged in, 675 
prognosis of, 675 
symptoms of, 674 
treatment of, 675 
in sca.rlet fever, 242 
in typhoid fever, 290 
Ascarides lumbricoides, 510 

causing peritonitis, 522 
Ascites, 520 

chylous, cirrrosis of liver in, 521 



INDEX. 



851 



Ascites, chylous, enlargement of spleen 
in, 521 
lesions of thoracic duct in, 

521 
syphilis and, 521 
tuberculosis and, 521 
diagnosis of, from cystic tumors, 

520 
dyspnoea in, 564 
etiology of, 521 
forms of, 520 
treatment of, 521 
Asphyxia in newborn, 187 
definition of, 187 
diagnosis of, 188 
etiology of, 187 
extra-uterine, 187 
intra-uterine, 187 
morbid anatomy of, 187 
prognosis of, 189 
symptoms of, 188 
treatment of, 189 
sudden death in, 20, 172 
Asthma crystals, 550 

in fibrinous bronchitis, 550 
dyspnoea in, 564 
in emphysema of lungs, 553 
thymic, 698 
Ataxia in cerebral palsy, 813 
hereditary, 821 

Argyll-Robertson pupil in, 821 
course of, 822 

differential diagnosis of, 822 
mental state in, 822 
muscular power in, 822 
occurrence of, 821 
prognosis of, 822 
sensory disturbances in, 822 
symptoms of, 821 
treatment of, 822 
Atelectasis in bronchopneumonia, 583 
foetal, 191 

acquired, 192 
compression, 192 
obstructive, 192 
of lung, 192 
in measles, 265 

pulmonary, convulsions in, 194 
Athetoid movements in cerebral palsy, 

813 
Athrepsia, 479 
Athyreosis, 689 
Atrophy, infantile, 479 
etiology of, 479 
morbid anatomy of, 480 
symptoms of, 480 
treatment of, 481 
of muscles, 45 
progressive muscular, 827 
Auricular ventricular septum, cyanosis 
in, 641 
defects of, 641 
Auscultation of chest, 561 



BABINSKI'S reflex in children under 
two years, 46 
in meningitis, 46, 315, 393-397 
Bacillus aerogenes capsulatus, 62 

coli communis in bacteriuria, 765 

in cystitis, 764 
diphtheriae, 341 

in bronchopneumonia, 582 
in endocarditis, 642 
in otitis, 733 

in rhinitis, diphtheritic, 531 
endocarditidis in endocarditis, 642 
foetidus in otitis, 733 
influenzae in otitis, 733 
pneumoniae, 556, 567 
proteus vulgaris in diarrhoea, 470 
pseudo-influenza in otitis, 733 
pyocyaneus in diarrhoea, 470 
in otitis, 733 
in pericarditis, 624 
in peritonitis, 521 
typhosus in bronchopneumonia, 582 
in endocarditis, 642 
in osteomyelitis, 730 
Bacteria, intestinal, 18 
of mouth, 424 
in woman's milk, 84 
Bacteriology of acute peritonitis, 521 
of jaundice, 516 
of scarlet fever, 249 
Bacterium coli in acute peritonitis, 521 
in osteomyelitis, 730 
in pericarditis, 624 
lactis aerogenes m cows' milk, 95 
mesentericus vulgatus in cows' milk, 
95 
Bacteriuria, 765 

pathogeny of, 765 
symptoms of, 765 
treatment of, 765 
Barley, dextrinized, 104 
gruels, dextrinized, 148 

use of, 148 
water, 104, 139 

as adjuvant to cows' milk, 104 
composition of, 104 
dextrinization of, 104 
preparation of, 104 
Barlow's disease, 721 
Basedow's disease, facial expression in, 36 
Bath, 48 

Brand, 61 

cold, 51 

daily, 50 

first, 49 

full, 61_ 

hardening with, 51 

kind of water used for, 50 

in premature infants, 51 

reaction in, 52 

tempei-ature of room, 50 

of water, 50 
time for, 51 



852 



INDEX. 



Bed of child, 55 
Bednar's aphthae, 196, 424, 431 
cause of, 432 
treatment of, 432 
Beef broths, 107 

preparation of, 107 
Beef-extracts, Armour's, 108 
Bovril, 108 

for invalids, 108 
Brand's essence, 108 
Liebig's, 108 
Veyr's, 108 
Beef-juice, 105 

Armour's, 105 
Bovinine, 105 
Brand's, 105 
composition of, 106 
Valentine's, 105 
varieties of, 105 
Wyeth's, 105 
Bell's paralysis, 814 
Benger's food, composition of. 111 
Biedert's cream mixture, 123 

composition of, 124 
formulae of, 124 
proteids in, 124 
Bile ducts, congenital obstruction of, 517 
formation of, 453 
glycocholic acid in, 453 
in newborn, 161 

physiological function of, 162 
taurocholic acid in, 453 
Binder, 57 

Birth paralysis, position of head in, 35 
Blennorrhoea of umbilicus, 201 
Blindness, test for, 37 
Blood in acute peritonitis, 522 

in cerebrospinal meningitis, 317 
circulation of, in adult, 27 
at fourteenth year, 27 
in nevvborn, 27 
at third year, 27 
culture in sepsis neonatorum, 198 
in diphtheria, 345 
diseases of, 703 
haemoglobin in, 704, 705 
in malaria, 299 
in measles, 268 
in newborn, 161 

amount of, when cord ligated 
quickly, 161 
slowly, 161 
erythrocytes in, 161, 703 
histology of, 161 
leucocytes in, 161, 704 
in rachitis, 669 
in scarlet fever, 245 
specific gravity of, 705 
in tuberculous meningitis, 317, 398 
Boat-shaped abdomen, 40 
Body, length of, 23-27 

temperature, 162 
Bone changes in craniotabes, 730 



Bone changes in cretinism, 670, 694 
in Mongolian idiocy, 670 
in osteomyelitis, 731 
in otitis, 734 
in i-achitis, 664, 729 
in scorbutus, 723 
in syphilis, 670, 729 
Bones, craniotabes of, 730 
diseases of, 729 

pain in, significance of, 729 
lesions of, in rachitis, 662 
in scrofulosis, 372, 375 
in sepsis neonatorum, 197 
of skull, syphilis of, 730 
tuberculosis of, 730 
syphilis of, 729 
tuberculosis of, 729 
Botali ductus, 159, 176, 640 
Bottles, nursing, 101 
care of, 102 
warmer, Sobel's, 102 
Bovinine, composition of, 106 
Bovril's beef-extract, 107 

composition of, 108 
Bradycardia in hysteria, 779 
in lobar pneumonia, 571 
Brain, abscess of, in bronchiectasis, 558 
in scarlet fever, 241 
dropsy of, 801 
lesions of, in rachitis, 664 
tuberculosis of, 401 
tumors of, 807 

convulsions in, 808 
etiology of, 807 
frequency of, 807 
headache in, 808 
location of, 807-810 
nausea and vomiting in, 808 
optic neuritis in, 808 
symptoms of, 807 
Branchial cysts, 444 

atheromatous, 444 
hematocysts, 444 
mucous, 444 
serous, 444 
Brand bath, 61 

in treatment of typhoid fever, 
297 
Brand's beef-essence, 108 

beef-juice, composition of, 106 
beef-peptone, 106 
Breast, abscess of, 118 
caking of, 119,224 

as cause of dyspepsia in baby, 
457 
feeding, 120 
lymphangitis of, 118 
massage of, 119 
in newborn, 163 
milk in, 163 

analysis of, 164 
biochemical theory of, 164 
nursing at, 119 



INDEX, 



853 



Breathing, bronchial, in pneumonia, 574 
croupous, in laryngitis, 542 
mouth-, in infants, 560 
nasal in infants, character of, 560 
puerile types of, 563 
stridulous in laryngitis, 543 
Breck's feeding-bottle, 182 
Brick dust deposit in urine, 746 
Bronchi, casts of, 550 

diseases of, 546 
Bronchial breathing in pneumonia, 574 
nodes in congenitally weak, 177 
voice in pneumonia, 575 
Bronchiectasis, 556 

abscess of brain in, 558 

of lung in, 559 
amyloid liver in, 558 
complications of, 558 
course of, 559 
cysts in, 556 
definition of, 556 
deformity in, 557 
diagnosis of, 558 
dyspncea in, 557 
empyema in, 558 
etiology of, 557 
expectoration in, 557 
fever in, 557 
forms of, 556 

gangrene of lungs, in, 558 
haemoptysis in, 559 
liver abscess in, 558 
morbid anatomy of, 556 
perforation of lung in, 558 
pleurisy in, 558 
pneumonia in, 558 
symptoms of, 557 
treatment of, 559 
tuberculosis in, 558 
Bronchitis, acute simple, 546 

auscultation in, 549 
causation of, 546 
in exanthemata, 546 
palpation in, 548 
pathology of, 546 
percussion in, 548 
physical signs of, 548 
in rachitis, 547 
sputum in, 548 
sudden death in, 20, 173 
treatment of, 549 
amyloid kidney in, 558 
chronic, 551 

in emphysema of lungs, 551 
with emphysema, 551 
in scrofulosis, 373 
in congenitally weak, 183 
fibrinous, 550 

asthma crystals in, 550 
casts in, 550 
complications of, 551 
cyanosis in, 550 
definition of, 550 



Bronchitis, fibrinous, diagnosis of, 551 
dyspnoea in, 550 
etiology of, 550 
fever in, 550 
morbid anatomy of, 550 
rales in, 550 
splenic tumor in, 550 
symptoms of, 550 
treatment of, 551 
tuberculous, 551 
tumors of spleen in, 550 
in influenza, 305 
in measles, 265 
tuberculous, in fibrinous bronchitis, 

551 
in typhoid fever, 290 
Bronchophony in pleurisy, 612 
Bronchopneumonia, acute, 581 
arthritis in, 590 
bacteriology of, 582 
cerebral symptoms, 587 
complicating diarrhoeal disease, 
589 
diphtheria, 589 
measles, 588 
scarlet fever, 589 
typhoid fever, 588 
varicella, 589 
course of, 589 

prolonged, 591 
diagnosis of, 594 
equivocal signs of, 593 
etiology of, 582 
fever curve in, 585 
forms of, 583 

gastro-enteric tract in, 586 
mode of onset of, 583 
morbid anatomy of, 582 
occurrence of, 581 
osteomyelitis in, 590 
pericarditis in, 590 
physical signs of, 592 
prognosis of, 592 
pulse in, 586 
sputum in, 586 
symptoms of, 583 
termination of, 590 
treatment of, 595 
of heart in, 596 
of temperature in, 596 
atelectasis in, 583 
bacillus diphtherise in, 582 

typhosis in, 582 
complicating empyema, 600 
in congenitally weak, 177, 183 
cough in, 583 
cyanosis in, 583 
in dipththeria, 349 
dyspnoea in, 583 
fever in, 585 

gangrene of lungs in, 590 
in influenza, 305 
in measles, 265 



854 



INDEX. 



Bronchopneumonia in meningitis, 590 
otitis in, 590 
pericarditis in, 590 
persistent, 598 

blood in, 598 

definition of, 598 

diagnosis of, 599 

physical signs of, 599 

symptoms of, 598 

treatment of, 599 
in pertussis, 587 
pneumococcus in, 582 
recurrent, 591 
in scarlet fever, 245 
sudden death in, 20 
in typhoid fever, 290 
Buhl's disease, 215 

definition of, 215 

diagnosis of, 215 

etiology of, 215 

morbid anatomy of, 215 

symptoms of, 215 

hemorrhages in, 212 
umbilical. 206 
Burgoyne's beef-juice, composition of, 
106 

C^CUM in chronic appendicitis, 505 
Calculi, renal, 746 
Calomel inhalation, 64, 65 
Calorie, definition of, 76 
Calories, 29, 129 

in carbohydrates, 76 
in fat, 76 
in proteids, 76 
in milk, 76 

required in breast-fed infant, 77 
in bottle-fed infant, 78 
Caloriometric method of artificial infant- 
feeding, 129 
Cantoni's salt solution, 68 
Caput succedaneum, 24 
Carbohydyates, 75 

in blood and lymph, 75 
in human milk, 75 
in liver, 75 
in muscles, 75 
Carbolic acid poisoning, 48 
Carbonic acid gas, 78, 170 
Carcinoma of kidney, 755 
Cardiac area, 39 

in emphysema, 552 
disease, dyspnoea in, 564 

face in, 36 
munnurs, accidental, 655 
Carnick's peptonoids, composition of, 106 

soluble food. 111 
Casein, 82 

difference between human and cows' 

milk, 93 
in cows' milk, 82, 93 

definition of, 93 
formation of, 82 



Casein in human milk, 82 
pseudonuclein in, 82 
Casts in fibrinous bronchitis, 550 

of pseudomembrane in diphtheritic 

rhinitis, 531 
in urine of newborn, 32 
Catalepsy, 777, 783 

symptoms of, 783 
Cataract, congenital, nystagmus in, 37 
Catarrh, nasal, 527 
Catarrhal appendicitis, 503 
croup, 542 
diphtheria, 345 
icterus, 516 
influenza, 305 
Cephalohsematoma, 24, 227 
diagnosis of, 228 
internal haematoma, 228 
of newborn, 227 
occurrence of, 228 
pathogenesis of, 228 
symptoms of, 227 
treatment of, 229 
Cerebellar tumors, gait in, 47 
Cerebral palsy, 810 
gait in, 48 

muscular atrophy in, 48 
patellar reflex in, 46 
symptoms in pneumonia, 567 
Cerebrospinal fluid, admixture of blood 
in, 767 
albumin in, 769 
cytology of sediment in, 769 
in epidemic cerebrospinal men- 
ingitis, 768 
in hydrocephalus, chronic, 768 
normal, 767 
pressure of, 769 
specific gravity of, 767 
in suppurative meningitis, 769 
in tuberculous meningitis, 769 
meningitis, 310 
blood in, 317 
endocarditis in, 642 
Cereo, 149 
Chancre, 402 
Chapin's dipper, 132 

method of artificial feeding, 149 
Chapman's whole flour, 112 
Charcot-Leyden crystals in amoebic dys- 
entery, 489 
Chest, cardiac area of, 39 
in cerebral diseases, 560 
circumference of, 25 
in effusion, 560 
in emphysema, 560 
examination of, immediate 38 
mediate, 37 
position in, 37 
fremitus in, 40 
inspection of, 37 
normal movements of, 560 
palpation of, 39 



INDEX. 



855 



Chest, percussion of, 40 

painful, in rachitis, 40 
puncture of, exploratory, in pleurisy, 

613, 614 
rachitic, 25 
shape of, 25 

tendon of diaphragm in, 25 
transverse diameter in, 25 
wall, resiliency of, 561 
Cheyne-Stokes respiration, 392, 560 

in tuberculous meningitis, 392, 
397 
Childhood, definition of, 17 
Children, sudden death in, 19 
Chlorosis, 707 

occurrence of, 708 
Cholecystitis in typhoid fever, 288 
Cholera, Asiatica, epidemic of, due to 
milk, 95 
infantum, 469 

definition of, 473 
diagnosis of, 474 
duration of, 474 
occurrence of, 473 
prognosis of, 474 
symptoms of, 473 
treatment of, 475 
Chondrodystrophia foetalis, 675 
definition of, 675 
diagnosis of, 678 
forms of, 676 
history of, 678 
morbid anatomy of, 676 
prognosis of, 678 
symptoms of, 678 
Chondrogen, 72 

Chorea, cardiac murmurs in, 795 
classification of, 791 
definition of, 791 
diagnosis of, 796 
disturbances of sensation in, 794 
duration of, 797 
electrical reaction of muscles in, 

794 
endocarditis in, 645 
epidemics of, 791 
etiology of, 791 
following scarlet fever, 246 
frequency of, 791 
habit movements in, 796 
Huntington's, 791 
in infectious diseases, 792 
insaniens, 791, 798 
definition of, 798 
fatal forms of, 798 
operations in, 799 
symptoms of, 798 
treatment of, 799 
involuntary muscles in, 794 
laryngeal, 791 
lymphatism in, 792 
major, 791 
minor, 791 



Chorea, morbid anatomy of, 792 
occurrence of age, 791 

season, 791 
pericarditis in, 795 
prognosis of, 797 
relation of infectious diseases to, 

792 
rheumatic poison in, 794 
rheumatism in, 418, 792 
Sydenham's, 791 
symptoms of, 792 
cardiac, 794 

frequency of, 795 
mental, 796 
mode of onset, 792 
motor, 793 
temperature in, 795, 796 
tongue in, 793 
treatment of, 797 
urine in, 794 
wrist-drop in, 793 
Chvostek symptom, 392 
Circulation in adult, 27 
at fourteenth year, 27 
in newborn, 27, 159 
changes in, 159 
at third year, 27 
Circulatory system, diseases of, 624 
Cirrhosis of liver, 518 

chylous ascites and, 521 
Clothing of infant, 57 
Cocoa, acorn, 108 

composition of, 108 
preparation of, 108 
Cold compress, 61 

temperature of, 61 
pack, 61 
Colic in bottle-fed infants, 142, 463 
treatment of, 143 
intestinal, inspection of abdomen in, 

41 
with tympanites, 463 
CoUes' law, 406 
CoUogen, 72 

Colon, congenital dilatation of, 495 
forms of, 495 
symptoms of, 495 
treatment of, 496 
Colostrum before labor, 79 
color of, 79 
composition of, 79 
corpuscles in, formation of, 80 

size of, 80 
decomposition of, on nipple, 118 
in last month of pregnancy, 79 
Lourie's bodies in, 79 
reaction of, 79 
specific gravity of, 79 
time of transition into milk, 80 
when first formed, 118 
Colprostasis differentiated from perito- 
nitis, 523 
Coma, diabetic, 681 



856 



INDEX. 



Condylomata of larynx, 545 
Congenital absence of gall-bladder, 514 

of oesophagus, 445 
anomalies, 174 

of tongue, 440 
constipation, 489 
dilatation of colon, 495 
disease of heart, 636 
heart disease, cyanosis in, 636 
dilatation in, 636 
murmurs in, 636 
hydrocele, 175 
hypertrophy of limb, 45 
ichthyosis, 846 
rachitis, 661 

stricture of oesophagus, 445 
stridor, 784 

rachitis in, 670 
syphilis, 405 

of nose, 527 

omphalorrhagia in, 206 
Congenitally weak, 176 

artificial feeding in, 185 

bronchial nodes in, 177 

bronchitis in, 183 

constipation in, 177 

definition of, 176 

diarrhoea in, 178 

etiology of, 176 

laceration of liver in, 182 

meconium in, 177 

morbid anatomy of, 176 

peptonized milk in, 186 

pericarditis in, 177 

sclerema in, 177 

sepsis in, 177 

sudden death in, 172 

weight in, 178 
Conjunctivitis, blenorrhoeica, 221 

simple, in newborn, 223 
in measles, 268 
photophobia in, 37 
Conrad's lactobutyrometer, 90 

lactodensimeter, 90 
Constipation, 489 
acquired, 490 
acute, 490 

in breast-fed infants, 492 
chronic, 491 

anal fissure in, 491 

growths in, 491 
congenital, 177, 489 

absence of anus in, 489 
in congenitally weak, 177 
in cyclic vomiting, 459 
in dilated stomach, 465 
foreign bodies in, 490 
with frozen milk, 101 
habitual, 492 
hereditary, 492 
in intussusception, 490 
in peritonitis, 490 
in pyloric stenosis, 468 



Constipation in rachitis, 492 
strangulation in, 490 
symptoms of, 492 
treatment of, 493 

cathartics in, 494 
dietetic, 493 
enemata in, 494 
massage in, 495 
medicinal, 494 
in typhoid fever, 298 
Constitutional diseases, 661 
Convulsions in cerebral palsy, 813 
in infancy, 771 

classification of, 771 
diagnosis of, 775 

from brain abscess, 775 

tumors, 775 
from meningitis, 775 
from tetany, 775 
etiology of, 772 
occurrence of, 772 
pathogeny of, 773 
prognosis of, 775 
treatment of, 775 
baths in, 776 
posture in, 776 
in pertussis, 338 
in pulmonary atelectasis, 194 
in scarlet fever, 234 
in tumors of brain, 808 
Coomb's malted food, 112 
Cord, umbilical. See Umbilical cord. 
Corneal ulcer, photophobia in, 37 

ulcerations in measles, 268 
Coxa vara, 43 

Cracked-pot sound in pneumonia, 574 
Cranial bones, indentation of, 225 
Cranioschisis, 831 
Craniotabes, 664, 730 

bone changes in, 730 
in laryngismus stridulus, 785 
in rachitis, 664 
Crede's method, 52 
Cretinism, 689 

bone changes in, 670, 694 
diagnosis of, 694 
etiologv of, 693 
forms of, 689 

endemic, 689 
sporadic, 689 
morbid anatomy of, 693 
occurrence of, 689 
skin abscesses in, 692 
symptoms of, 690 
blood in, 691 
genitals in, 691 
hands in, 692 
skin in, 691 
tongue in, 692 
treatment of, 695 
Croup, catarrhal, 542 

spasmodic, 542 
Croupy breathing in laryngitis, 542 



INDEX. 



857 



Crowing, inspiratory, in retropharyngeal 

abscess, 536 
Cutis sabacea, 846 
Cyanosis, angiospastic, 196 

in bronchopneumonia, 583 

in congenital heart disease, 636 

in fibrinous bronchitis, 550 
Cyclic albuminuria, 741 

vomiting, acetone breath in, 460 
Cystitis, 764 

bacillus coli communis in, 764 

in diphtheria, 764 

etiology of, 764 

in exanthemata, 764 

gonococcus in, 764 

symptoms of, 764 

treatment of, 764 

tubercle bacilli in, 764 

in typhoid fever, 764 

in vulvovaginitis, 764 
Cysts, branchial, 444 

of oesophagus, 444 

in bronchiectasis, 556 

of kidney, 754 

causing peritonitis, 522 

of liver, causing peritonitis, 522 

of spleen, causing peritonitis, 522 

DACTYLITIS syphilitica, 412 
Darby's fluid meat, 106 
Davidson nipple shield, 118 
Deaf-mutism in scarlet fever, 240 
Deafness in scarlet fever, 240 
Death, sudden, in newborn, 171 

cause of, 172 
Delorme's operation, 621 
Dentition, 425 

amorphism, 429 
convulsions in, 773 
dental erosions, 428 
Hutchinson's teeth, 426 
incision of gums in, 429 
infantile, 428 
microdentism, 428 
pathology of, 429 
in rachitis, 426 
in syphilis, 426 
ulcer in pertussis, 338 
Dermatitis exfoliativa, 195, 845 
course of, 846 
etiology of, 845 
history of, 845 
prognosis of, 846 
symptoms of, 845 
treatment of, 846 
Dew method of artificial respiration, 

190 
Diabetes, acetone breath in, 681 
furuncles in, 681 
insipidus, 682 

symptoms of, 682 
treatment of, 683 
lichen in, 681 



Diabetes mellitus, 680 

diagnosis of, 681 
etiology of, 680 
occurrence of, 680 
symptoms of, 681 
pruritus in, 681 
Diabetic coma, 681 
Diapers, 53 

washing of, 53 
Diaphragm, defects of, 191 
Diarrhoea, bacillus proteus vulgaris in, 
470 
in congenitally weak, 178 
facial expression in, 36 
fat, 74, 127 

in bottle babies, 143 
in glandular fever, 308 
in influenza, 305 

pyocyaneus in, 470 
summer, 469 

enteroclysis in, 68 
with frozen milk, 101 
Dicrotic pulse, 27 
Dicrotism, 27 

Digestive functions in newborn, 161 
Dilatation of heart, 659 
Diphtheria, 340 

antitoxins in, 88 

bacilli in human milk, 88 

bacillus of, 341 

blood in, 345 

bronchopneumonia in, 349 

complicated by bronchopneumonia, 

349,_ 589 
complications of, treatment of, 369 
contagion of, 340 
course of, 349 
cystitis in, 764 
diagnosis of, 354 

from aphthae, 356 
from diphtheroid, 354 
from herpes of fauces, 356 
from laryngismus stridulus, 355 
from stomatitis, 355 
from traumatic sore throat, 356 
duration of, 349 
endocarditis in, 642 
epidemic of, due to milk, 95 
etiology of, 340 
exanthema, 354 
forms of, 344 

catarrhal, 345 
follicular, 345 
laryngeal, 348 
septic, 346 

malignant, 347 
gastro-enteritis in, 350 
general infection, 342 
incubation of, 340 
mastoiditis in, 345 
in measles, 264 
morbid anatomy of, 343 
nephritis in, 350 



858 



INDEX. 



Diphtheria in newborn, 340 
of nose, 354 
ophthalmia, 353 
otitis in, 345 
paralysis in, general, 352 

of heart in, 351 
in pertussis, 354 
pleuritis in, 349 
prognosis of, 356 
retropharyngeal abscess in, 350 
in scarlet fever, 236 
sensory nerves in, 352 
of skin, 353 
symptoms of, 344 
toxins of, 341 

in human milk, 88 
treatment of, 357 

antitoxin in, 357 
dosage of, 358 
effect of, 358 

on blood, 359 
on kidney, 360 
on temperature, 359 
eruptions following, 359 
method of, 358 
time of injection of, 358 
disinfection in, 357 
extubation in, 368 

dangers of, 368 
general, 360 
intubation in, 362 

indications for, 362 
method of, 365 
local, 361 
prophylactic, 357 
in typhoid fever, 290 
of vulva, 353 
Diphtheritic ophthalmia, 353 
paralysis, 352 
ataxia in, 47 
patellar reflex in, 46 
position of head in, 35 
bacillus diphtherise in, 531 
rhinitis, 531 
Diphtheroid, 236, 354, 370 
course of, 370 
diagnosis of, 370 
etiology of, 370 
occurrence of, 370 
symptoms of, 370 
treatment of, 370 
Diplococcus intracellularis, 311 

pneumoniae, 565, 567 
Diverticula of oesophagus, 444 
Dropsy of brain, 801 
Drugs, dosage of, 60 

hypodermic injection of, 60 
Ductus arteriosus, open, 640 
symptoms of, 640 
Botalli, closure of, 159 
open, 640 

in premature infants, 176 
Dwarfism and idiocy, 695 



Dysentery, 483 
amoebic, 489 

Charcot-Leyden crystals in, 489 
etiology of, 489 
stools in, 489 
in arthritis, 487 
complications of, 487 
course of, 486 
definition of, 483 
enteroclysis in, 68 
epidemic of, due to milk, 95 
etiology of, 483 
intestinal perforation in, 487 
symptoms of, 485 
treatment of, 487 
Dyspepsia, acute gastric, 457 
cause of, 457 
symptoms of, 457 
treatment of, 458 
infantile, asparagus causing, 437 
Dysphagia in oedema glottidis, 544 
Dyspnoea, forms of, 563 

in abdominal tumor, 564 
in ascites, 564 
in asthma, 564 
in bronchopneumonia, 583 
in cardiac disease, 564 
in fever, 564 

in fibrinous bronchitis, 550 
in laryngeal disease, 564 
in oedema glottidis, 544 
in pain, 564 
in pericarditis, 627 
in pulmonary disease, 564 
Dysuria, 743 

in measles, 268 
treatment of, 744 

EAK, diseases of, 733 
Eclampsia, rachitis in, 670 
in scarlet fever, 244 
Ecthyma in scrofulosis, 373 
Ectopia cruralis testis, 174 

perinealis testis, 174 
Eczema, 837 

of anus as cause of fissure, 507 
etiology of, 839 
forms of, 838 

impetiginous, 838 
seborrhoeic, 839 
of nipples, 118 
treatment of, 840 
Ehrlich diazo reaction in typhoid fever, 

294 
Emboli, mycotic, 644 
Emphysema, cardiac area in, 552 
of lungs, 551 

adenoids in, 552 

asthma in, 553 

chronic bronchitis in, 551 

deformity of chest in, 553, 554 

enlarged tonsils in, 552 

frequency of, 551 



INDEX. 



869 



Emphysema of Inngs, lymphatism in, 
552 
morbid anatomy of, 551 
physical signs of, 552-554 
prognosis of, 555 
symptoms of, 552 
treatment of, 555 
Empyema, 600 

adhesions, pleural, 620 

treatment of, 620 
bacteriology of, 603-605 
bilateral, 621 

prognosis of, 621 
treatment of, 621 
in bronchiectasis, 558 
complicated by bronchopneumonia, 

600 
course of, 615 
diagnosis of, 607-609 
displacement of heart in, 612 
of liver in, 611 
of pleural fold in, 610 
of viscera in, 611 
effusion of, purulent, 601 
serous, 601 

etiology of, 602 
symptoms of, 606 
forms of, primary, 602 

secondary, 602 
frequency of, 601 
hemorrhagic, 622 
metapneumonic, 607 
morbid anatomy of, 602 
perforating, 614 

metallic tinkle in, 614 
signs of, 614 
symptoms of, 614 
physical signs of, 608-610 
prognosis of, 615 
pulsating, 614 
puncture of chest in, exploratory, 

613, 614 
in scorbutus, 622 

etiology of, 622 
temperature in, 606 
termination of, 615 
treatment of, 63 6-620 
in typhoid fever, 605 
Encephalitis, 390 
Encephalocele, 831 
Endemic cretinism, 689 
Endocarditis, acute, 642 

bacteriology of, 642 
course of, 648 
etiology of, 642 
forms of, 644 

choreic, 645, 648 
rheumatic, 645, 648 
location of, 642 
modes of infection in, 643 
morbid anatomy of, 643 
physical signs of, 647 
prognosis of, 648 



Endocarditis, acute, recurrent, 645 

rheumatic pains in, 644 

secondary to exanthemata, 645 

symptoms of, 644 

temperature in, 644 

tonsils as portals of infection, 
643 

toxins in, 643 

treatment of, 649 

vegetations in, 643 
bacillus diphtherise in, 642 

endocarditidis in, 642 

typhosus in, 642 
cardiac, chronic, 647 
in cerebrospinal meningitis, 642 
in chorea, 645 

complicating rheumatism, 418, 648 
in diphtheria, 642 
in erythema multiforme, 843 

nodosum, 642 
in follicular amygdalitis, acute, 539 
following mumps, 333 
gonococcus in, 642 
maternal nursing in, 114 
in measles, 642 
murmurs in, accidental, 648 

hsemic, 648 
pneumococci in, 642 
in pneumonia, 642, 645 
pustulosa, 643 
recurrent, 645 
in scarlet fever, 244, 642 
in sepsis, 642 
septic, 645 

blood in, 646 

Cheyne-Stokes respiration in, 
647 

chronic, 647 

diagnosis of, 647 

dilatation in, 647 

etiology of, 646 

frequency of, 645 

petechias in, 647 

symptoms of, 646 

temperature in, 646 
toxins in, 642 
in tuberculosis, 642 
in typhoid fever, 642 
ulcerosa, 643 
verrucosa, 643 
Enemata, high, 68 
low, 68 
nutritive, 70 
oil, 70 

stimulating, 69 
Enteratoma of umbilicus, 200 
Enteritis follicularis, 482 
Enteroclysis, 68 

in dysentery, 68 

in exhausting disease, 68 

in nephritis, 68 

in summer diarrhoea, 68 

in typhoid fever, 68 



860 



INDEX. 



Enterocolitis, 482 
etiology of, 482 
morbid anatomy of, 482 
symptoms of, 482 
treatment of, 483 
Enuresis, diurna, 759 

diagnosis of, 760 
symptoms of, 760 
treatment of, 760 
nocturna, 759 
Enzymes, 79 

in human milk, 84 

definition of, 84 
Epilepsy, 788 
aura, 788 
convulsions in, 788 
definition of, 788 
diagnosis of, 789 

from cerebral tumors, 789 
from palsy, 789 
etiology of, 788 
maternal nursing in, 114 
occurrence of, 788 
in palsy, infantile, 788 
symptoms of, 788 
temperature in, 789 
treatment of, 790 
Epistaxis, 532 

amount of blood-loss, 532 
symptoms of, 532 
Epstein's pearls, 196, 424, 824 
Erb's palsy, 225, 820 
Erysipelas, pneumonia in, 565 
Erythema exudativum, 843 

cardiac disease in, 843 
symptoms of, 843 
treatment of, 844 
multiforme, 843 

endocarditis in, 843 
nodosum, 416, 420, 843 
endocarditis in, 642 
Erythrocytes in childhood, 703 
in infancy, 703 
in newborn, 161 
Escherich's method of infant-feeding, 

125 
Eskay's food, composition of, 112 
Estlandei-'s operation, 620 
Excreta, 77 

carbonic acid gas, 78 
nitrogen, 77 
urea, 77 
water, 78 
Eyes in newborn, 52 

cleansing of, 52 

FACIAL expression in Basedow's dis- 
ease,_36 
in cardiac disease, 36 
in congenital syphilis, 36 
in diarrhoea, 36 
in facial paralysis, 36 
in hydrocephalus, 36 



Facial expression in Mongolian idiocy, 
36 
in nuclear palsy, 36 
in rachitis, 36 
palsy, 814 

paralysis due to forceps, 225 
Fseces in newborn, 169 
Fairchild's panopeptone, 106 
"Falona," composition of, 112 
Farina, diastased, 112 
Fats, animal, 74 

amount assimilated from cows' 
milk, 74 
from human milk, 74 
in body, 74 
composition of, 74 
as food, 7 
calories in, 82, 83 

in human milk, 83 
in various milks, 82 
color of, in cows' milk, 93 

in human milk, 83 
diarrhoea, 127 
digestion of, 454 
globules, 83 
in cows' milk, 83 
in human milk, 83 
melting-point of, 83 
in newborn, 127 
in percentage-feeding, 127 
percentage of, high, 138 

low, 144 
specific gravity of, in human milk, 

83 
at third month, 127 
Fatty degeneration of liver, 518 

of newborn. See Buhl's dis- 
ease. 
Fauces, herpes of, differentiated from 

diphtheria, 356 
Febrile murmurs, 655 

charactei-s of, 655 
Feeding of infants, artificial, 123 

after sixth month, 151 
Biedert's mixture, 124 
Chapin's method of, 149 
in congenita] ly weak, 185 
dextrinized gruels, 149 
diluent in, 139 
Escherich's method of, 125 
fat diarrhoea in, 143 
from eighteenth month to 

end of second year, 153 
from ninth to twelfth month, 

151 
from twelfth to eighteenth 

month, 151 
greenish movements in, 143 
Heubner-HoflTman method 

of, 125 
home modification of milk 

in, 130 
Keller's method of, 149 



INDEX. 



861 



Feeding of infants, artificial, laboratory 
method of, 123 
low percentage of fats in, 
144 
of proteids in, 144 
Meig's mixture, 124 
method of calculating per- 
centage in, 133 
number of nursings in, 128 
peptonized milk in, 145 
percentage method, 126 
proteids, 127 
quantity at each feeding, 

128 
rich, 147 

Eotch's method of, 125 
simple milk dilution in, 123 
Soxhlet method of, 125 
table of feedings, 140 
vomiting in, 144 
whey method of, 145 
breast, 120 

colic in, 120 

signs of efficient feeding, 120 
of inefficient feeding, 
120 
symptoms due 
to, 120 
variability of stools in, 120 
mixed, 113, 122 

overfeeding in, 122 
overflow vomiting in, 122 
Fermentation, sugar, 127 
Ferments of mouth, 423 
Fibrinous bronchitis, 550 
Fibromata of larynx, 546 
Fissure of anus, 507 
Foetal atelectasis, 191 

rickets, so-called, 675 
Follicular enteritis, 482 

tonsillitis, 345 
Folliculitis abscedens, 844 
Fontanelles, posterior lateral and anterior, 
in rachitis, 664 
time of closure of, 24, 35 
Food preparations, infant, 102 

when to use them, 147 
Foramen ovale, manner of closure of, 159 
open, 641 

cyanosis in, 641 
Foreign bodies in larynx, 546 
in nose, 532 

symptoms of, 532 
treatment of, 532 
Formulae, food, method of constructing, 

133-135 
Fragilitas ossium idiopathica, 678 
Frame food diet, composition of, 112 
Freeman nursing-bottle, 101 
Fremitus, examination for, 40 

normal chest, 561 
Friedreich's disease, 821 

patellar reflex in, 46 



Furuncles in diabetes, 681 
Furunculosis, 844 

occurrence of, 844 

symptoms of, 844 

treatment of, 844 

GAIT, ataxic, after fevers, 46 
in cerebellar tumors, 47 
in diphtheritic paralysis, 47 
in Friedreich's ataxia, 46 
in pseudohypertrophic paralysis, 
46 
limping, 48 

in infantile paralysis, 48 
spastic, in spastic paralysis, 47 
in young infants, 47 
Gall-bladder, congenital absence of, 514 

in newborn, 161 
Gangrene of lungs in bronchiectasis, 558 
in bronchopneumonia, 590 
in scarlet fever, 245 
of pinna in measles, 268 
of umbilical cord, 49 
of umbilicus, 202 
Gangrenous appendicitis, 502 
Gas in subphrenic abscess, 622 
Gastro-enteritis, 469 
bacteria in, 470 
classification of, 470 
condensed milk in, 103 
course of, 472 
definition of, 469 
diagnosis of, 474 
diarrhoea in, 476 

differentiated from peritonitis, 523 
in diphtheria, 350 
morbid anatomy of, 471 
nephritis in, 748 
in pertussis, 338 
prognosis of, 472 
stomach washing in, 65 
symptoms of, 471 
treatment of, 475 
baths in, 477 
drugs in, 478 
hypodermoclysis in, 477 
prophylactic, 475 
rectal enemata, 477 
vomiting in, 476 
Gavage, 67 

in congenitally weak, 184 
Genitalia, care of, 54 
Gibson's drain method in empyema, 620 
Glandular fever, 308 

diagnosis of, 309 
diarrhoea in, 308 
etiology of, 308 
lymph nodes in, 308 
nephritis in, 309 
symptoms of, 308 
throat in, 309 
treatment of, 309 
Globulin, 82 



862 



INDEX. 



Glottis, oedema of, 544 
course of, 544 
definition of, 544 
etiology of, 544 
forms of, 544 
morbid anatomy of, 544 
prognosis of, 544 
symptoms of, 544 
treatment of, 545 
Glycocholic acid, 162, 453 
Glycosuria, alimentary, 681 
Gonococcus in cystitis, 764 
in endocarditis, 642 
in osteomyelitis, 730 
in peritonitis, 523 
in vulvovaginitis, 761 
Gonorrhoeal infection of mouth, 437 
ophthalmia, 52 
proctitis, 508 
rheumatism, 419 
Grand mal, 789 
Granuloma of umbilical cord, 49 

of umbilicus, 200 
Gummata of larynx, 545 
Gyrospasm, 800 

HABIT movements, 799 
spasms, 799 
Hsematoma of sternomastoid, 227 
Hsematuria, 744 

etiology of, 744 

in scorbutus, 725 

urine in, 744 
Haemoglobinuria, 745 

definition of, 745 

etiology of, 745 

morbid anatomy of, 745 

of newborn, 216 

prognosis of, 745 

symptoms of, 745 

treatment of, 745 
Haemophilia, etiology of, 716 

hemorrhages in, 212 

nature of, 716 

treatment of, 717 
Haemoptysis in bronchiectasis, 559 
Hall's method of artificial respiration, 190 
Hands, toilet of, 54 
Hardening, 51 
Head, examination of, 35 

measurements of, 24 

nodding of, 800 

position of, in amaurotic idiocy, 35 
in birth paralysis, 35 
in defective vision, 37 
in diphtheritic paralysis, 35 
in Potts' disease, 35 

shape of, 35 
Headache in tumors of brain, 808 
Hearing, development of, 32 

in newborn, 168 
Heart, action of, in laryngismus, 786 

apex-beat of, 39, 633 



Heart, auscultation of, 634 

cardiac area of, in thin chests, 39 
in cardiac hypertrophy, 633 
congenital disease of, 636 

aortic disease in, 637 
cardiac dilatation in, 636 
hypertrophy in, 636 
cyanosis in, 636 
defects of septum in, 637 
diagnosis of lesions in, 637 
murmurs in, 636 
open ductus arteriosis in, 

638 
pulmonary artery in, 637 
transposition of, 638 
valvular anomalies in, 637 
dilatation of, 659 

acute, sudden death in, 659 
occurrence of, 659 
in pertussis, 337 
symptoms of, 659 
transudates in, 659 
treatment of, 660 
diseases of, 632 

congenital, dilatation in, 636 
maternal nursing in, 114 
hypertrophy of, 659 
occurrence of, 659 
symptoms of, 659 
treatment of, 660 
inspection of, 633 
marking of dulness of, 634 
measurements of, ventricles to left 

and right sternum, 636 
palpation of, 634 
paralysis of, in diphtheria, 351 

in thymus death, 700 
percussion of, 634 
position of, 633 

prsecordial area of, in hypertrophv, 
633 
in normal chest, 633 
in pericarditis, 633 
in rachitis, 633 
pulmonary valves of, 634 
size of, 633 
tuberculosis of, 388 
valvular disease of, chronic, 650 
angina in, 653 
cardiac insufiiciency in, 

651 
etiology of, 650 
frequency of, 650 
pallor in, 652 
palpation in, 651 
physical signs of, 650 
prognosis of, 650 
rheumatic cases, 653 
symptoms of, 651 
treatment of, 653 
ventricles in, 636 
Hemianopsia, hysterical, 778 
Hemiplegia, spastic, 810 



INDEX. 



863 



Hemorrhages in BuU's disease, 212 
in conjunctiva, 212 
in haemophilia, 42 
intestinal, in polypi gut, 508 
in mouth, 212 
in newborn, 210, 212 
in nose, 212 

in sepsis of newborn, 195, 212 
skin, 212 
of stomach, 212 
in syphilis, 212 
in Winckel's disease, 212 
Hemorrhagic diathesis, 715 
classification of, 715 
empyema, 622 
pleurisy, 622 
rachitis, 661, 721 
Hennig's symptom, 204 
Henoch's purpura, 719 
Hepatitis, suppurative, 519 
Hereditary ataxia, 821 
Hernia, umbilical, 207 
Herpes of fauces differentiated from 
diphtheria, 356 
of tonsils, 540 
Heubner-Hoffman method of infant-feed- 
ing, 125-129 
History, taking, 34 
Hodgkin's disease, 686, 715 
Horlick's malted milk, composition of, 

111 
Hum, venous, 656 
Huntington's chorea, 791 
Hutchinson's teeth^ 426 
Hydrsemia, 743 

without kidney lesion, 743 
Hydrocele, congenital, 175 
of cord, 175 

treatment of, 175 
Hydrocephaloid condition, 36, 803 
Hydrocephalus, 390, 801 
acute internal, 328 
chronic, cerebrospinal fluid in, 768 
congenital, external, 804 
internal, 801 
diagnosis of, 803 

from hydrencephaloid, 803 
from rachitis, 803 
etiology of, 801 
face in, 802 
forms of, 801 
morbid anatomy of, 801 
prognosis of, 803 
symptoms of, 802 
treatment of, 804 
facial expression in, 36 
in i-achitis, 669 
Hydrochloric acid in stomach of newborn, 

161 
Hydromyelocele, 832 
Hydronephrosis, 754 
Hydropericardium in scarlet fever, 243 
nephritis in, 243 



Hydrotherapy, 61 

Hydrothorax in scarlet fever, 243 

nephritis in, 243 
Hygiene of infant, 48 
Hypertrophy of heart, 659 

in congenital disease, 636 

of muscles, 45 

of thymus gland, 697 
Hypodermoclysis, 62 
Hysteria, 776 

bradycardia in, 779 

catalepsy in, 777 

course of, 779 

dancing mania in, 778 

definition of, 776 

diagnosis of, 779 

disturbances of sensation in, 778 
of vision in, 778 

duration of, 779 

epidemics of, 778 

etiology of, 776 

hystero-epilepsy in, 777 

mental influences in, 777 

motor manifestations in, 777 

psychic, 777 

tachycardia in, 779 

treatment of, 779 
Hysterogenetic zones, 778 

TCHTHYOSIS, congenital, 846 
J. Icterus, catarrhal, 516 
infectious, 517 
neonatorum, etiology of, 211 
symptoms of, 212 
treatment of, 211, 212 
simple, enlargement of spleen in, 517 
Idiocy, amaurotic, 805 

diagnosis of, 807 
etiology of, 805 
morbid anatomy of, 806 
ocular changes in, 806 
prognosis of, 807 
spastic phenomena of, 806 
symptoms of, 806 
Mongolian, 694 

bone changes in, 670 
treatment of, 696 
nystagmus in, 37 

secondary to cerebral hemorrhage, 
189 
Imperial granum, composition of, 112 

use of, 147 
Incubators, 180 

cause of sepsis, 195 
cleansing of, 181 
indications for use of, 181 
Lion,_180 

infections due to, 180 
Sloane maternity, 180 
Tarnier, 180 
temperature of, 181 
wards, 183 
Indicanuria, 31 



864 



INDEX. 



Infancy, definition of, 17 
Infant, congenitally weak, 176 
atelectasis in, 176 
bath of, 183 
bronchial nodes in, 177 
bronchitis in, 183 
bronchopneumonia in, 176 
causes of, 176 

in syphilis, 176 
in tuberculosis, 176 
in twins and triplets, 
176 
clothing of, 183 
death in, causes of, 178 
ductus Botalli in, 176 
feeding of, 182 
artificial, 185 
breast, 184 
mixed, 186 
gavage in, 184 
hemorrhages in, 177 
hemorrhagic pneumonia in, 

176 
management of, 178 
pericarditis in, 177 
pneumonia in, 177 
prognosis of, 178 
sepsis in, 176 
symptoms of, 177 
development of, mental, 32 

physical, 32 
feeding, 71 

artificial, 141 
colic in, 142 
constipation in, 141 

treatment of, 142 
fat diarrhoea in, 142 
greenish movements in, 143 
spitting in, 142 
vomiting in, 144 
empiricism in, 71 
milk in, condensed, 103 

raw, 100 
principles of, 71 
foods, artificial, 108, 110 

carbohydrates in, 110 
composition of, 111 
exclusive use of, 109 
fat in, 110 
flour. 111 
maltose in, 110 
objections to, 109 
prolonged use of, 109 

causing rachitis, 
109 
scurvy, 109 
proteids in, 110 
utility of, 109 
in weaning, 110 
maltose in. 111 
•sudden death of, 19 
Infantalism, 695 
Infantile amblyopia, nystagmus in, 37 



Infantile atrophy, 479 

paralysis, 822 
gait in, 48 
Infections, filth, 18 
Inflammation of thymus gland, 698 
Influenza, 303 

albuminuria in, 307 

angina in, 305 

bronchitis in, 305 

bronchopneumonia in, 305 

cerebrospinal meningitis in, 306 

definition of, 303 

diagnosis of, 307 

diarrhoea in, 305 

differentiated from measles, 269 

duration of, 307 

etiology of, 304 

forms of catarrhal, 305 
endemic, 305 
epidemic, 305 
pandemic, 305 

incubation in, 304 

lobar pneumonia in, 305 

mode of infection in, 303 

morbid anatomy of, 304 

mumps complicating, 333 

nephritis in, 307, 357 

in newborn, 303 

pneumococcus in, 304 

pneumonia in, 565 

prognosis of, 807 

symptoms of, 305 
throat, 305 

treatment of, 307 
Inhalations, 64, 65 
Intestinal catarrh, sudden death in, 20 

colic, inspection of abdomen in, 41 

digestion, 452 

juices, 453 

parasites, 509 

perforation in typhoid fever, 291 
frequency of, 291 
symptoms of, 291 
time of, 291 
treatment of, 297 

residue, 454 

worms, 509 
Intestine, acute obstruction of, 496 

diseases of, 448 

classification of, 448 

perforation of, in dysentery, 487 

polypoid tumors of, 42 
Intoxication, acid, 479 
Intussusception, 496 

in breast-fed infants, 121 

causing peritonitis, 522 

condition of abdomen in, 42 

diagnosis of, 499 

etiology of, 496 

frequency of, 497 

inspection of abdomen in, 41 

rectal exploration in, 42 

spontaneous cure of, 500 



INDEX. 



865 



Intussusception, symptoms of, 497 

tenesmus, 498 

treatment of, 500 

tumor in, 498 

varieties of, 496 

vomiting in, 497 
Invagination differentiated from perito- 
nitis, 523 
Iodine in human milk, 87 
Iron in human milk, 73, 83 

JAMES' bottles in empyema, 620 
Jaundice, 516 

bacteriology of, 516 
duration of, 516 
morbid anatomy of, 516 
in newborn, 163 
occurrence of, 516 
symptoms of, 516 
treatment of, 517 
Joints, affections of, in varicella, 276 
crepitus in, 43 
examination of, 42 
in measles, 267 
mobility of, 43 
palpation of, 43 
in scrofulosis, 375 
suppuration of, due to vaccination, 

280 
tuberculosis of, 43 

KELLER'S malt-soup extract, compo- 
sition of, 150 
method of infant-feeding, 149 
Keratin, 72 

Kernig's symptom in meningitis, 46, 315, 
392,397 
in pneumonia, 46 
in typhoid fever, 46 
Kidney, amyloid, in bronchitis, 558 
carcinoma of, 755 
diagnosis of, 757 
duration of, 757 
symptoms of, 756 
cysts of, 754 

causing peritonitis, 522 
diseases of, 741 
floating, 42, 741 
growths of, 754 

treatment of, 758 
palpation of, 741 
sarcoma of, 755 

diagnosis of, 755 
symptoms of, 755 
small, in acute yellow atrophy, 520 
tuberculosis of, 757 
tumors of, 703, 754, 755 

rectal exploration for, 42 
simulating enlarged liver, 515 
uric acid infarction of, 32 
weight of, 741 
Kissing, 33 
Koch's peptone, composition of, 106 

56 



Koplik spots, 261, 262 
Kumyss, 107 

analysis of, 107 

manufacture of, 107 

LABORATORY method of infant-feed- 
ing, 123, 126 
Laborde method of artificial respiration, 

190 
Lactalbumin, 82 
Lactation, food during, 86, 89 
Lactobutyrometer, Conrad's, 90 
Lactodensimeter, Conrad's, 90 
Landry's paralysis, patellar reflex in, 46 
Lanugo, 163 
Larvae taenia, 511 
Laryngeal chorea, 791 
diphtheria, 348 
stridor, congenital, 784 
Laryngismus stridulus, 785 

complications of, 787 
craniotabes in, 785 
death in, 787 

sudden, 20 
definition of, 785 
diagnosis of, 787 
enlarged thymus in, 786 
morbid anatomy of, 786 
occurrence of, 785 
prognosis of, 787 
rachitis in, 670 
symptoms of, 786 
treatment of, 787 
Laryngitis, acute catarrhal, 542 
diagnosis of, 543 

from diphtheria, 543 
etiology of, 542 
prognosis of, 543 
symptoms of, 542 
treatment of, 543 
breathing in, cramp, 542 

stridulous, 543 
phlegmonous, 544 

stridulous, differentiated from diph- 
theria, 355 
submucous, 544 
Larynx, cicatrices in, 545 
condylomata of, 545 
diseases of, 542 
fibromata of, 546 
foreign bodies in, 546 

prognosis of, 546 
symptoms of, 546 
treatment of, 546 
growths of, 546 

symptoms of, 546 
treatment of, 546 
gummata of, 545 
gummatous infiltration of, 545 
papillomata of, 546 
peculiarities of, 366 
syphilis of, 545 

diagnosis ot 545 



866 



INDEX. 



Larynx, syphilis of, prognosis of, 545 
treatment of, 545 
tuberculosis of, 388, 545 
frequency of, 545 
treatment of, 545 
Laughing, 33 
Lecithin, 72 

in proteids, 83 
Leptomeningitis, acute, 325 

definition of, 310, 325 
etiology of, 325 
occurrence of, 325 
symptoms of, 326 
Leucocytes in infancy and childhood, 704 

in newborn, 161 
Leukaemia, 711 

changes in blood in, 712 

in acute form, 713 
definition of, 711 
etiology of, 711 
forms of, 711 
occurrence of, 711 
prognosis of, 714 
symptoms of acute form of, 712 

of chronic form of, 714 
treatment of, 715 
Leukocythsemia, 711 
Lichen in diabetes, 681 
scrofulosorum, 373 
Liebig's beef-extract, composition of, 108 

peptone, composition of, 106 
Lime-water, 139 
Lingua geographica, 441 
etiology of, 441 
symptoms of, 442 
Lipase, 84 
Liver, abscess of, 519 

in bronchiectasis, 558 
as cause of peritonitis, 522 
course of, 519 
symptoms of, 519 
treatment of, 519 
acute yellow atrophy of, 519 
amyloid, in bronchiectasis, 558 
anatomy of, 513 
cirrhosis of, 518 

chylous ascites and, 521 
etiology of, 518 
morbid anatomy of, 518 
symptoms of, 518 
cyst of, causing peritonitis, 522 
diseases of, 513 

displacements of, in empyema, 515 
dulness in peritonitis, 522 
enlargements of, 515 
in abscess, 519 
in anaemia infantum, 515 
bile-ducts in, 517 
in cirrhosis, 518 
in congenital obstruction, 517 
in fatty liver, 518 
in rachitis, 515 
in simple icterus, 517 



Liver, enlargements of, in syphilis, 515, 
518 
examination of, 513 
fatty degeneration of, 518 
laceration of, in congenitally weak, 

182 
measurements of, 514 
palpation of, 513 
peptonoids, 106 
percussion of, 514 
in pseudoleuksemic ansemia, 515 
pulsation of, 655 
in rachitis, 515 
syphilis of, 515, 518 

histological forms of, 518 
tumors of, phantom, 515 
Lobar pneumonia differentiated from 
acute appendicitis, 504 
in influenza, 305 
Lourie's bodies in colostrum, 79 
Lumbar puncture, 767 

amount of fluid withdrawn, 769 
indications for, 770 
instruments for, 769 
operation for, method of, 769 
place of puncture in, 769 
in sepsis, 198 

in treatment of tetanus, 210 
in tuberculous meningitis, 399 
Lung, abscess of, in bronchiectasis, 559 
in bronchopneumonia, 590 
atelectasis of, 192 
diagnosis of, 194 
etiology of, 192 
prognosis of, 194 
symptoms of, 193 
treatment of, 194 
varieties of, 192 
diseases of, 560 
emphysema of, 551 
gangrene of, in bronchiectasis, 558 
in bronchopneumonia, 590 
in scarlet fever, 245 
normal limits of, 561 
perforation of, in bronchiectasis, 558 
size of, 560 
syphilis of, 187 
Lupus in scrofulosis, 373 
Lymph nodes, bronchial, 374 

symptoms of enlarged, 383 
congenital syphilis of, 685 
diseases of, 685 
distribution of, 685 
in exanthemata, 686 
in glandular fever, 308 
large, in chronic nasal catarrh, 

530 
in lymphatism, 685 
in measles, 267 

mediastinal, enlarged in bron- 
chopneumonia, 583 
in mumps, 332 
in i*achitis, 686 



INDEX. 



867 



Lymph nodes, retropharyngeal, 534, 685 
in scalp irritation, 685 
in scarlet fever, 241 
in scrofulosis, 372, 374 
in tonsillar infection, 685 
tuberculous, 583, 685 

Lymphadenitis, acute, 686 
chronic, 687 

occurrence of, 687 
symptoms of, 687 
treatment of, 687 
retropharyngeal, 534 

Lymphadenoma, 715 

Lymphangitis of breast, 118 

Lymphatism, 698 

with adenoids, 533 

Lymphosarcoma, 686 

McBUENETS point in appendicits, 
504 

Macewen's sign, 316, 398 
Macroglossia, 440 

hypertrophica congenita, 440 
Ivmphatica congenita, 440 
Malarial fever, 298 
age in, 298 
blood in, 299 
definition of, 298 
diagnosis of, 302 
etiology of, 299 
incubation in, 298 
morbid anatomy of, 300 
pneumonia in, 565 
relapses of, 301 
symptoms of, 300 
treatment of, 302 
Malformations, sudden death in, 172 
Maltose in infant foods. 111 
Mania in scarlet fever, 244 
Marantic infants, peritonitis in, 522 
Marasmus, 479 

Keller's malt extract in, 150 
Mastoid inflammation in scarlet fever, 
241 
region, anatomv of, 736 
swelling, 738, 739 
tenderness, 737 
Mastoiditis, 736 
course of, 739 
diagnosis of, 739 
in diphtheria, 345 
etiology of, 736 
in exanthemata, 737 
frequency of, 737 
otoscopic examination, 738 
occurrence of, 737 
physical signs of, 738 
prophylaxis of, 739 
in scarlet fever, 241 
in scrofulosis, 374 
symptoms of, 737 
treatment of, 740 
in typhoid fever, 288, 738 



Maternal nursing, 112 

contraindications to, 113 

in acute infectious diseases, 

114 
in Bright's disease, 114 
in epilepsy, 114 
in heart disease, 114 
in malignant disease, 114 
in nervous diseases, 114 
in syphilis, 114 
in tuberculosis, 114 
intervals of, 117 
nephritis in, 111 
placing of child to breast in, 117 
Matzoon, 107 
Measles, 260 

albuminuria in, 267 

amaurosis in, 268 

angina in, 264 

atelectasis in, 265 

blood in, 268 

bones in, 267 

bronchitis in, 265 

bronchopneumonia in, 265, 588 

complicated bv bronchopneumonia, 

265, 588 
conjunctivitis in, 268 
contagiousness of, 258 
corneal ulcerations in, 268 
diagnosis of, 269 

from antitoxin and drug erup- 
tions, 270 
from influenza, 269 
from rotheln, 270 
from scarlet fever, 270 
from syphilis, 270 
from typhoid fever, 270 
diphtheria in, 264 
dysuria, 268 
ear in, 268 
enanthema of, 261 
endocarditis in, 642 
eruption of mucous membrane in, 

261 
exanthema in, 263 
in first born, 257 
in foetus, 257 

gangrene of pinna in, 268 
heart in, 266 
immunity from, 258 
incubation of, 258 
intestines in, 266 
joints in, 267 
kidneys in, 267 
lymph nodes in, 267 
mouth in, 268 
mumps complicating, 333 
myocarditis in, 266 
nephritis in, 267 
nervous system in, 268 
neuritis following, 268 
noma following, 269 
nose in, 264 



868 



INDEX. 



Measles in newborn, 257 

contagiousness of, 258 
immunity of, 258 
incubation of, 258 
ordinary type of, 259 
otitis in, 268 
pericarditis in, 266 
pertussis in, 268 

following, 268 
photophobia in, 268 
prognosis of, 269 
sequela? of, 269 
temperature in, 260 
throat in, 264 
treatment of, 270 

bronchitis in, 272 
bronchopneumonia in, 272 
diphtheria in, 273 
ear in, 273 
eye in, 273 
general, 270 

laryngeal symptoms in, 272 
prophylactic, 271 
throat in, 273 
Meconium, 166 

bacteria in, 167 
bodies, 167 
color of, 166 
composition of, 167 
in congenitally weak, 177 
consistency of, 166 
odor of, 166 
plug, 166 
Mediastinal abscess in scarlet fever, 236 
Meigs' cream mixture, 124 

composition of, 124 
proteids in, 124 
Melsena neonatorum, 213 
diagnosis of, 214 
due to gastric ulcers, 213 

to intestinal ulcers, 213 
morbid anatomy of, 214 
in newborn, 213 
symptoms of, 214 
treatment of, 214 
Melancholia in scarlet fever, 244 

in typhoid fever, 290 
Melanodermie in Addison's disease, 728 
Mellin's food, composition of, 111 

use of, 147 
Memory, 33 
Meningitis, 309 

abdomen in, 40 
Babinski's reflex in, 46, 315 
bacteria m, 320 
boat-shaped abdomen in, 40 
in bronchopneumonia, 590 
cerebrospinal, 310 

anterior fontanelle in, 319 
Babinski reflex in, 46, 315 
blood in, 317 

cerebral symptoms in, 314 
complications of, 319 



Meningitis, cerebrospinal, course of, 321 
cytology of, 320 
diagnosis of, 321 

from pneumonia, 321 
from tubercular meningitis, 

321 
from typhoid fever, 321 
dilatation of ventricles in, 324 
diplococcus intracellularis in, 

310 
ear in, 319 

epidemic form of, 311 
etiology of, 310 
eye symptoms in, 316 
facial paralysis in, 316 
hypersesthesia in, 315 
influenza bacilli in, 306 
Kernig's symptom in, 315 
lumbar puncture fluid, 320 

method of, 324 
Macewen's sign in, 315 
micrococcus catarrhalis in, 311 
mode of infection in, 311 

onset in, 314 
morbid anatomy of, 312 
occurrence of, 312 
pneumococcus in, 311 
prognosis of, 322 
pulse in, 317 
respirations in, 317 
rigidity of neck in, 314 
sequelae of, 320 
skin in, 319 
spine in, 45 
spleen in, 319 
symptoms of, 312 

common type of, 313 
general, 414 
malignant type of, 312 
resembling malaria, 314 
tache cerebrale, 315 
temperature in, 318 
treatment of, 322 
classification of, 309 
complicated by bronchopneumonia, 

590 
forms of, primary, 309 

secondary, 310 
influenza bacilli in, 306 
Kernig's symptom in, 46 
pneumonia in, 565 
posterior basic, 326 

complications of, 327 
definition of, 326 
etiology of, 326 
occurrence of, 326 
prognosis of, 828 
symptoms of, 327 
treatment of, 328 
varieties of, 327 
in scarlet fever, 241 
of serosa, 328 

definition of, 328 



INDEX. 



869 



Meningitis of serosa, diagnosis of, 330 
etiology of, 329 
forms of, 328 
morbid anatomy of, 329 
occurrence of, 328 
symptoms of, 329 
spine in, 45 
tuberculous, 389 
vertical, 325 
Meningocele, 832 
spinalis, 832 
Meningo-encephalocele, 831 
Mesenteric lymph nodes, enlarged, in 
Addison's disease,728 
in glandular fever, 309 
Metabolism, 75 

in bottle-fed infants, 78 
disturbances of, 773 
in newborn infants, 169 
Metallic tinkle in perforating empyema, 
614 
in subphrenic abscess, 623 
Micrococcus catarrhalis, 311 

endocarditis capsulatus, 642 
rugatus, 642 
Microdontism, 428 
Micromelia, 675 
Milia, 163 
Miliaria alba, 845 

rubra, 845 
Milk of various animals, 82 
Milk, breast, amount taken in twenty-four 
hours, 85, 169 
calories in, 76 
composition of, from various animals, 

82 
condensed, 103 

analysis of, 104 
dilution of, 104 
in gastro-enteritis, 103 
infants fed on, 103 
cows', 93 

acidity of, 96 

analysis of, 93 

bacteria in, 94 

bacterium lactisaerogenes in, 95 

mesentericus vulgatus in, 95 
casein in, 82, 93 
fat in, 93 
infected, 95 

as cause of epidemic, 95 
method of obtaining, 96 
Pasteurization of, 94 
peptonization of, 98 
phosphorus in, waste of, 94 
proteids of, 93 
reaction of, 93 
specific gravity of, 93 
sterilization of, 94 
in summer, 99 
frozen, cause of constipation, 101 
of diarrhoea, 101 
fat globules in, 101 



Milk, human, agglutinins in, 88 
alexins in, 17, 79, 84 
amount of, consumed by infant, 
85 
secreted by breast, 85 
amylase in, 84 
analysis of, 89, 90, 92 
antitoxins in, 88 
bacteria in, 84 

of infectious disease in, 87 
carbohydrates in, 75 
casein, 81 

changes in daily, 86 
colostrum in, 79 
composition of, 81 
crescent-shaped bodies in, 83 
diphtheria bacilli in, 88 
dried, composition of, 111 
drugs in, 87 
effect of foods on, 86 

of menstruation on secre- 
tion of, 88 
of pregnancy on secretion 

of, 89 
of starvation on, 86 
enzymes in, 84 

examination of proteids in, 92 
fats in, 83 
iodine in, 87 
iron in, 73 
lipase in, 84 
pneumococci in, 88 
proteids in, 82, 87, 92 
reaction of, 84 
salts in, 83 

specific giuvity of, 84 
thumb-nail test in, 116 
time of appearance of, 80 
toxins in, 88 

of tubercle bacillus in, 
114 
tubercle bacilli in, 88 
typhoid bacilli in, 88 
water in, 83 
whey proteids in, 81 
modified, 130 

advantages of, 131 
various formulae of, 136 
number of colonies in litre of, 76 
Pasteurized, assimilation of, 99 

when to give it, 100 
peptonized, 102, 145 
cold method, 102 
in congenitally weak, 186 
with peptogenic milk powder, 

103 
with peptonizing tubes, 103 
percentages, method of obtaining, 

133-135 
powder, peptogenic, 103 
i-aw, from limited herd, 100 
in infant-feeding, 100 
twelve hours old, 100 



870 



INDEX. 



Milk, raw, when to give it, 101 
sterilized, assimilation of, 99 

as a cause of constipation, 98 

of scurvy, 98 
when to give it, 100 
sugar, digestion of, 452, 454 
tests for cleanliness of, 133 
top, 131 
witches, 164 
Mongolian idiocy, 694 

bone changes in, 670 
palpebral fissure in, 36 
Monocercomonas hominis in diarrhceal 

stools, 489 
Morbidity in childhood, 18 

of newborn, 17 
Morbilli, 257 

haeraorrhagica, 263 
Morbus maculosis Werlhofii, 717 
Morphine, administration of, 59 
Mortality, 18, 19 

in newborn, 171 
Morton's fluid, 835 
Mouth, bacteria of, 57, 424 
breathing in infants, 560 
care of, 57 
diseases of, 438 
ferments in, 423 
gonorrhoeal infection of, 437 
normal, characteristics of, 424 
physiology of, 423 
ulceration of, 58 

at angle of, 430 
Mucous membranes, pigmentation of, 728 
Multiple sclerosis, patellar reflex in, 46 
Mumps, 330 
age in, 330 
albuminuria in, 333 
complications of, 333 
complicating influenza, 333 
measles, 333 
pneumonia, 333 
typhoid fever, 333 
varicella, 333 
diagnosis of, 334 
etiology of, 330 
incubation in, 331 
lymph nodes in, 332 
morbid anatomy of, 331 
in newborn, 330 
prognosis of, 334 
symptoms of, 331 
treatment of, 334 
urine in, 333 
Murmurs, cardiac, accidental, 655 
anaemic, 655 
aortic, 655 
arterial, 656 
congenital, 636 
febrile, 655 
haemic, 655 
Muscle sense in newborn, 167 
Muscles, atrophy of, 45 



Muscles, hypertrophy of, 45 

spasm of, 45 
Muscular atrophy, facio-scapulo-humeral, 
827 
juvenile, 827 
Myelocystocele, 832 
Myelomeningocele, 832 
Myocarditis, 656 

bacteriology of, 657 

bradycardia, 658 

in chronic heart disease, 658 

diagnosis of, 658 

etiology of, 657 

forms of, 657 

frequency of, 656 

high pulse in, 658 

in measles, 266 

morbid anatomy of, 656 

in pericarditis, 626 

in pneumonia, 658 

pulse respiration ratio in, 658 

septic cases of, 658 

symptoms of, 657 

treatment of, 658 

in typhoid fever, 289 
Myotonia, definition of, 784 

NASAL breathing in infants, 560 
catarrh, acute, 527 

course of, 528 
diagnosis of, 528 
etiology of, 527 
prognosis of, 529 
symptoms of, 528 
treatment of, 529 
chronic, 530 

etiology of, 530 
symptoms of, 530 
treatment of, 531 
Naso-pharynx, diseases of, 527 
Nausea in tumors of brain, 808 
Neave's food, composition of, 112 
Nephritis, acute, 746, 747 

constipation in, 750 
course of, 751 
difiuse, 747 
duration of, 751 
etiology of, 746 
exudative, 746 
headache in, 750 
heart in, 750 
lungs in, 750 
morbid anatomy of, 747 
cfidema in, 750 
parenchymatous, 748 
primary forms of, 751 
pulse in, 750 
temperature in, 750 
urine in, 748 
in acute follicular amgydalitis, 539 
with acute yellow atrophy of liver, 

520 
chronic difiuse, 751 



INDEX. 



871 



Nephritis, chronic diffuse, forms of, 751 
symptoms of, 751 
treatment of, 752-754 
cyclic albuminuria difi'erentiated 

from, 742 
in diphtheria, 350 
enteroclysis in, 68 
in gastro-enteritis, 748 
in glandular fever, 309 
glomerular, 746 
in influenza, 307, 357 
in maternal nursing. 111 
in measles, 267 
pneumonia in, 565 
in scarlet fever, 243 
tubular, 746 
Nervous system in newborn, 167 

in sepsis neonatorum, 197 
Nestle's milk food, composition of. 111 
Neurasthenia from loss of sleep, 55 
Neuritis following measles, 268 
multiple, 817 

course of, 818 

definition of, 817 

diagnosis of, 819 

etiology of, 817 

frequency of, 817 

gait in, 818 

morbid anatomy of, 817 

muscle atrophy in, 45 

occurrence of, 817 

sensory disturbances of, 818 

symptoms of, 818 

treatment of, 820 
optic, in tumors of brain, 808 
Newborn, amylolytic ferments in, 161 
asphyxia in, 187 
atelectasis in, 192 
bile in, 161 
blood in, 161 
body temperature in, 162 
breasts in, 163 
Buhl's disease in, 215 
caking of breasts in, 224 
cardiac action in, 157 
cephalohaematoma of, 227 
circulation in, 27, 160 
consciousness in, 168 
definition of, 17 
desquamation of, 17 
digestive functions in, 161 
diphtheria of, 340 
disease of umbilicus of, 199 
erythrocytes in, 161 
excretions of, 169 
eye reflexes in, 168 
eyes in, 52 
faeces in, 169 
fats in, 127 
fatty degeneration of. See Buhl's 

disease, 
gall-bladder in, 161 
haemoglobinuria of, 216 



Newborn, hearing in, 168 

heat and cold, appreciation of, in, 

169 
hemorrhages in, 210, 212 

hydrochloric acid in, 161 
icterus in, 210 
injuries at birth, 225 
jaundice of, 163 
leucocytes in, 161 
mastitis in, 225 
measles in, 257 
mela^na in, 213 
metabolism in, 169 
morbidity of, 17 
mortality in, 171 
muscular power in, 167 

sense in, 167 
nervous system in, 167 
ophthalmia neonatorum in, 221 
osteomyelitis in, 730 
pain sense in, 169 
pancreatic secretion in,* 161 
patellar reflex in, 168 
pepsin in, 161 
peritonitis of, 208 
perspiration in, 163 
physiology of, 157 
pulmonary atelectasis in, 192 
pulse in, 160 
rectal excreta in, 166 
respiration in, 156 
saliva in, 161 
sclerema in, 217 
secretion of parotid gland in, 161 

of submaxillary gland in, 161 
sense of pain in, 169 

of smell in, 169 
sepsis in, 194 
septic infection in, 194 
simple conjunctivitis in, 223 

blennorrhoeica in, 221 
skin in, 163 

desquamation of, 837 

of sebaceous glands in, 163 
smell in, 169 
starch digestion in, 162 
sudden death in, 171 
taste in, 168 
temperature in, 162 
tetanus in, 208 
touch sense in, 169 
uric acid in, 166 
urine of, 29, 164 

albumin in, 166 

casts in, 32 
Winckel's disease in, 216 
Nipples, care of, 58, 102, 118 
development of, 118 
eczema of, 118 
fissured, treatment of, 118 
shield for, 118 
Nitrogen, excretion of, 77 
Nitroglycerin, 60 



872 



INDEX, 



Noma, 438 

bacillus of Babes in, 439 

diphtheria bacillus in, 439 

etiology of, 438 

following measles, 269 

prognosis of, 440 

symptoms of, 439 

treatment of, 440 
Nose, congenital syphilis of, 527 

deformity of septum of, 527 

diphtheria of, 354 

diseases of, 527 

examination of, 527 

foreign bodies in, 532 

symptoms of, 532 
treatment of, 532 

pseudomembranous inflammation of, 
240 

syringing of, 63 
Nursery, 55 

floor of, 56 

temperature of, 56 

ventilation of, 56 
Nursing, maternal. See Maternal nursing. 

physiology of act of, 423 

women, food for, 86 
Nutroa food, composition of, 112 
Nystagmus, 37 

in albinism, 37 

in congenital eatai-act, 37 

in corneal opacity, 37 

in idiocy, 37 

in infantile amblyopia, 37 

in rachitis, 37 

in spasmus nutans, 37 

OATMEAL gruel, 105 
analysis of, 105 
preparation of, 105 
(Edema of glottis, 544 

dysphagia in, 544 
dyspnoea in, 544 
of skin in scarlet fever, 243 
GEsophagitis, caustic, 446 
etiology of, 446 
symptoms of, 446 
treatment of, 446 
(Esophagus, bronchial cyst of, 444 
congenital absence of, 445 

stricture of, 445 
diverticula of, 444 
Omphalitis, 199 
Omphalorrhagia, 206 

in congenital syphilis, 206 
etiology of, 206 
occurrence of, 206 
in sepsis, 206 
symptoms of, 206 
treatment of, 206 
Onychia in typhoid fever, 289 
Opalisin, 82 

Ophthalmia, diphtheritic, 353 
gonorrhoeal, 52 



Ophthalmia neonatorum, 221 
complications of, 222 
diagnosis of, 223 
duration of, 222 
etiology of, 222 
prognosis of, 223 
prophylaxis of, 52 
symptoms of, 222 
treatment of, 223 
Opmus food, composition of, 112 
Optic neuritis in tumors of brain, 808 
Orthopnoea in pericarditis, 627 
Osteochondritis syphilitica, 411 
Osteogenesis imperfecta, 678 
definition of, 678 
differential diagnosis of, 680 
etiology of, 680 
morbid anatomy of, 679 
symptoms of, 679 
treatment of, 680 
Osteomyelitis, 198 

acute infectious, 730 

definition of, 730 
diagnosis of, 732 
etiology of, 730 
morbid anatomy of, 731 
prognosis of, 732 
symptoms of, 731 
treatment of, 732 
bacillus typhosus in, 730 
bacterium coli in, 730 
bone changes in, 731 
in bronchopneumonia, 590 
due to vaccination, 280 
in exanthemata, 731 
gonococcus in, 730 
joints in, 43 
in newborn, 730 
pneumococcus in, 730 
pneumonia in, 565, 731 
Otitis, acute, 733 

bacteriology of, 733 
course of, 735 
diagnosis of, 736 
etiology of, 733 
frequency of, 733 
morbid anatomy of, 733 
prognosis of, 736 
symptoms of, 734 
in acute follicular amygdalitis, 539 
bacillus diphtheria? in, 733 
f(etidus in, 733 
influenzje in, 733 
pyocyaneus in, 733 
bone changes in, 734 
in broncliopneumonia, 590 
in diphtheria, 345 
in measles, 268 
in scarlet fever, 240 
in typhoid fever, 288 
in varicella, 276 
Otogenic infections, 196 
Ovarian tumors, rectal exploration for, 42 



INDEX. 



873 



Overlying, 55 

Oxyuris vennicularis, 510 

chai-acters of, 511 

treatment of, 511 

in vaginitis, 761 
Ozaena in scrofulosis, 373 

PACIFIEKS, 55 
Palsy, birth, 225, 811 

symptoms of, 812 
cerebral, 810 
acute, 811 

symptoms of, 812 
ataxia in, 813 

athetoid movements in, 813 
convulsions in, 813 
diagnosis of, 813 
disturbances of sensation in, 

813 
etiology of, 810 
forms of, 810 
morbid anatomy of, 811 
paralysis in, 813 
postnatal, 811 
prognosis of, 814 
reflexes in, 813 
symptoms of, 812 
treatment of, 226, 814 
Erb's, 820 

definition of, 820 
differentiated from cerebral 

palsy, 821 
prognosis of, 821 
symptoms of, 820 
treatment of, 821 
facial, 814 

following basic brain dis- 
ease, 816 
caries of bone, 816 
otitis, 816 

operative treat- 
ment, 817 
occurrence of, 814 
rheumatic form of, 816 
symptoms of, 815 
obstetrical. See Palsy, Erb's. 
postnatal, 811 
Pancreas, ferments of, 453 

weight of, 453 
Pancreatic secretion in newborn, 161 
Panophthalmitis in scarlet fever, 241 
Papillomata of larynx, 546 
Paralysis, acute atrophic, 822 
atrophy in, 825 
course of, 825 
diagnosis of, 826 

from cerebral palsy, 
• 826 
from Erb's pai-alysis, 

826 
from multiple neuritis, 
826 
etiology of, 823 



Paralysis, acute atrophic, galvanic reac- 
tion, muscle in, 825 
growth of bone in, 825 
morbid anatomy of, 826 
occurrence of, 822 
onset of, 823 
paralysis in, 823 
prognosis of, 825 
sequelae of, 825 
symptoms of, 823 
treatment of, 827 
amaurotic, position of head in, 35 
Bell's, 814 

birth, position of head in, 35 
symptoms of, 225 
treatment of, 226 
in cerebral palsy, 813 
diphtheritic, 352 

position of head in, 35 
Erb's,225 
essential, 822 

of heart in diphtheria, 351 
infantile, 822 

gait in, 48 
pseudohypertrophic, 45, 828 
complications of, 830 
course of, 829 
definition of, 828 
diagnosis of, 830 
electrical reaction of muscles 

in, 829 
etiology of, 828 
morbid anatomy of, 830 
reflexes of, 829 
symptoms of, 828 
treatment of, 830 
varieties of, 830 
of tongue. 191 
Paranephritis, 759 
Paraplegia, spastic, 47 

electrical contractility in, 47 
gait in, 47 
Parasites, intestinal, 509 

symptoms of, 509 
varieties of, 509 
Parasyphilis, 406 
Parotid gland, secretion of, in newborn, 

161 
Parotitis, epidemic, 330 

in typhoid fever, 288 
Pasteurization, 97 

among the poor in summer, 99 
efifect of, on milk. 99 
Pasteurizer, Freeman's, 97 
Patellar reflexes, 46 
Pavor nocturnus, etiology of, 790 

forms of, with adenoids, 790 
with hallucinations, 790 
prognosis of, 790 
tj-eatment of, 790 
Peliosis rheumatica, 419, 718 
Pelvis, deformity of, in rachitis, 667 
Pemphigus neonatorum, 847 



874 



INDEX. 



Pemphigus neonatorum, definiiion of, 847 
forms of, 847 
prognosis of, 847 
symptoms of, 847 
treatment of, 847 
Peptone preparations, 106 
Peptonized milk, 106, 145 
Percussion, 40 

Perforative appendicitis, 502 
Pericarditis, 624 

abdominal pain in, 41 
apex-beat in, 627 
bacillus pyocyaneus in, 624 
bacteriology of, 624 
bacterium coli in, 624 
bronchopneumonia in, 590 
in chorea, 795 
in congenitally weak, 177 
definition of, 624 
diagnosis of, 630 

differentiated from pleural efl:u- 
sion, 630 
dyspnoea in, 627 
effusion in, 628 
etiology of, 624 
in exanthemata, 624 
fibrinous, 924 
foetal, 624 
forms of, 624 
friction-sound in, 629 
heart in, 633 
in measles, 266 
mode of infection in, 624 
morbid anatomy of, 626 
myocarditis in, 626 
occurrence of, 624 
orthopnoea in, 627 
physical signs of, 627 
pleuropericardial friction in, 630 
pneumococcus in, 624 
prognosis of, 631 
puncture of pericardium in, 631 
purulent form of, 624 
in scarlet fever, 245 
symptoms of, 626 
treatment of, 631 
tuberculous form of, 624 
Pericardium, adherent, 632 
etiology of, 632 
symptoms of, 632 
diseases of, 624 
tuberculosis of, 388 
Perinephritic abscess differentiated from 
acute appendicitis, 504 
simulating appendicitis, 504 
Perinephritis, 759 
Perioesophageal abscess, 446 
diagnosis of, 447 
etiology of, 447 
prognosis of, 447 
symptoms of, 447 
treatment of, 448 
Periostitis, hemorrhagic, 721 



Periproctitic abscess, 487 
Peritoneum, diseases of, 520 

tuberculosis of, 383 
Peritonism, gonococcal, 523 
Peritonitis, abdomen in, 40 
acute, 521 

blood in, 522 

bacteriology of, 521 

bacterium coli in, 521 

complications of, 523 

course of, 523 

diarrhoea in, 522 

differential diagnosis of, 523 

etiology of, 521 

pain in, 522 

physical signs of, 522 

prognosis of, 523 

symptoms of, 522 
appendicitis and, 522 
ascarides lumbricoides causing, 522 
bacillus pyocyaneus in, 52 
chronic simple, 525 
constipation in, 490 
differentiated from colprostasis, 535 

from gastro-enteritis, 523 
foetal, 523 
gonococcal, 523 

etiology of, 523 

forms of, 524 

prognosis of, 524 

treatment of, 524 
gonococcus in, 523 
inspection of abdomen in, 41 
liver abscess as cause of, 522 • 

in marantic infants, 522 
of newborn, 208 
perforative, acute, 523 
pneumococcal, 524 

course of, 524 

diagnosis of, 525 

etiology of, 524 

occurrence of, 525 

primary, 524 

prognosis of, 525 

secondary, 524 
pneumococci in, 521, 524 
proteus vulgaris in, 521 
septic, boat-shaped abdomen in, 41 
tuberculous, acute, 522 

diflferentiated from acute ap- 
pendicitis, 504 
Perleche, 430 

course of, 430 
definition of, 430 
diagnosis of, 430 
occurrence of, 430 
symptoms of, 430 
Pernicious anaemia, 720 
Pertussis, bronchopneumonia in, 587 
convulsions in, 338 
convulsiva, 334 

bacteriology of, 335 

convulsions in, 338 . 



INDEX. 



875 



Pertussis convulsiva, diagnosis of, 338 
dilatation of heart in, 337 
gastro-enteritis in, 338 
hemorrhage in, 338 
incubation in, 335 
dilatation of heart in, 337 
diphtheria in, 354 
following measles, 268 
g-astro-enteritis in, 338 
in measles, 268 

melancholia in, 338 
morbid anatomy of, 335 
mortality in, 338 
in newborn, 334 
occurrence of, 334 
prophylaxis of, 338 
psychoses of, 338 
symptoms of, 335 
treatment of, 338 
Petit mal, 789 
Peyei-'s patches enlarged in Addison's 

disease, 728 
Pfeiffer's fever, 308 
Phlebitis umbilicalis, 204 
meningitis in, 204 
peritonitis in, 205 
pleuritis in, 204 
pyaemia in, 204 
treatment of, 206 
Phlegmon of umbilicus, 201 
Phlegmonous laryngitis, 544 
Phosphorus in cows' milk, 129 
Photophobia, 37 

in measles, 268 
Pinna, gangrene of, in measles, 268 
Pin worm, 511 
Play, 54 ^ 

Pleura, diseases of, 600 
tuberculosis of, 388 
Pleurisy, 600 

abdominal pain in, 41 
bacteriology of, 603 
in bronchiectasis, 558 
bronchophony in, 612 
dry, 600 

diagnosis of, 601 
etiology of, 600 
forms of, 600 
frequency of, 600 
infrequency of, in children, 600 
pain in, 601 
prognosis of, 601 
symptoms of, 600 
treatment of, 601 
with effusion, 601 
hemorrhagic, 622 

occurrence of, 622 
prognosis of, 622 
metapneumonic, 607 
Pleuritic pain simulating appendicitis, 504 
Pleuritis in diptheria, 349 

diptheritic, bacillus diphtheriae in, 
531 



Pleuritis in scarlet fever, 245 
Pleuroplegia, 36 

Pneumococci in endocarditis, 642 
in human milk, 88 
in influenza, 304 
in osteomyelitis, 730 
in pericarditis, 624 
in peritonitis, 521, 524 
Pneumococcus in bronchopneumonia, 582 
Pneumonia, abdominal pain in, 41 
alba, 407 

bronchial breathing in, 574 
in bronchiectasis, 558 
broncho- 581 
catarrhal, 581 
central, 579 
chill in, 567 

complicating fibrinous bronchitis, 551 
cracked-pot sound in, 574 
crepitant rale, 574 
croupous, 565 
in erysipelas, 565 
fever in, 565 
fibrinous, 565 

hemorrhagic, in premature, 176 
hydrotherapy in, 579 
in influenza, 565 
Kernig's symptom in, 46 
lobar, 565 

blood in, 572, 573 

bradycardia in, 571 

chills of reinvasion of, 571 

complications of, 575 

cough in, 572 

crisis in, 568 

definition of, 565 

delirium in, 572 

diagnosis of, 578 

from influenza, 579 
from meningitis, 579 
from typhoid fever, 579 

differentiated from acute appen- 
dicitis, 504 

etiology of, 567 

invasion of, 567 

lysis of, 570 

melancholia in, 572 

morbid anatomy of, 566 

occurrence of, 565 

otitis in, 575 

pericarditis in, 577 

physical signs of, 573 

first stage, 573 
second stage, 574 
third stage, 575 

prognosis of, 578 

in scarlet fever, 245 

seat of disease, 565 

symptoms of, 567 

temperature in, 569-571 

treatment of, 579 

tympanites in, 581 
lobular, 581 



876 



INDEX. 



Pneumonia in malarial fever, 565 
in meningitis, 565 
mumps complicating, 333 
in nephritis, 565 
osteomyelitis in, 565, 731 
in rheumatism, 565 
in sepsis neonatorum, 195 
of short duration, 575 
sudden death in, 173 
symptoms of, cerebral, 567 
in typhoid fever, 289, 565 
in typhus fever, 565 
in varicella, 276 
voice in, 575 
Poliomyelitis, acute anterior. See Atro- 
phic paralysis, acute muscular 
atrophy in, 45 
patellar j-eflex in, 46 
Polyuria, 682 

Pott's disease, muscular spasm in, 45 
position of head in, 35 
spine in, 44 
Premature infants, 176 

asphyxia in, 191 
Proctitis, 508 

gonorrhoeal, 508 
Proglottides, bothriocephalus latus, 510 

taenia solium, 510 
Progressive muscular atrophy, 827 
Prolapsus ani, 506 

etiology of, 506 
symptoms of, 506 
treatment of, 506 
Proteids, calories in, 76 
casein in, 82 
chemical analysis of, 82 
in human milk, 82 

varieties of, 82 
percentage of, in adult foods, 76 
in body, 73 
in infant foods, 76 
in whey, 81 
Proteus vulgaris in peritonitis, 521 
Pruritis in diabetes, 681 
Pseudocroup, 542 
Pseudodiphtheria, 236 

bacillus, 341 
Pseudodiphtheritic stomatitis, 438 
Pseudohypertrophic paralysis, 828 
gait in, 46 

muscle hypertrophy in, 45 
Pseudoleukaemia, 715 
Pseudoleuksemic anaemia, 708 
blood in, 710 
course of, 710 
etiology of, 708 
history of, 708 
liver in, 708 
morbid anatomy of, 706 
occurrence of, 708 
spleen in, 708 
symptoms of, 709 
treatment of, 710 



Psoas muscle spasm, 45 
Psychic hysteria, 777 
Ptyalin, 453 

Pulmonary artery, stenosis of, 638 
clubbed fingers in, 639 
con us of, 638 
cyanosis of, 639 
murmur in, 639 
physical signs of, 640 
ventricular hypertrophy in, 
640 
Pulse at birth, 27, 160 
dicrotic, 27, 28 
during sleep, 27 
effect of crying on, 27 
respiration ratio of, 27 
rhythm of, 27 
Puro, composition of, 106 
Purpura, diagnosis of, 719 
Henoch's, 719 
rheumatica, 718 

definition of, 718 
etiology of, 719 
prognosis of, 719 
symptoms of, 718 
treatment of, 719 
simple, 716 

etiology of, 716 
prognosis of, 716 
treatment of, 716 
Pyelitis, 758 

prognosis of, 758 
symptoms of, 758 
treatment of, 759 
Pyelonephritis, 758 
Pyloric stenosis, 467 

constipation in, 468 
etiology of, 467 
morbid anatomy of, 467 
prognosis of, 468 
symptoms of, 468 
treatment of, medical, 468 
surgical, 469 
Pyopneumothorax, 614 
signs of, 614 
subphrenicus, 622 
symptoms of, 614 

AUININE, administration of, 59 

RACHISCHISIS, 830 
Kachitic hand, 668 
Rachitis, 661 

abdomen in, 668 
abdominal distention in, 41 
acute, 721 

simple bronchitis in, 547 
ansemia of, 669 
blood in, 669 
bone changes in, 664 

lesions in, 662 
brain lesions in, 664 



INDEX. 



877 



Bachitis, cardiac area in, 39 

chest in, 25 

congenital, 661 
stridor in, 670 

constipation in, 492 

craniotabes in, 664 

curvature of spine in, 665 

definition of, 661 

defoi-mity of extremities in, 667 
of hip in, 668 
of pelvis in, 667 
of tibia in, 668 

dentition in, 425 

diagnosis of, 671 

duration of, 669 

in eclampsia, 670 

etiology of, 661 

facial expression in, 36, 669 

fontanelles in, 24 

frequency of, 662 

head in, 664 

hemorrhagic, 661, 721 

hydrocephalus in, 669 

intestinal disturbances in, 668 

in laryngismus stridulus, 670 

liver in, 669 

morbid anatomy of, 662-664 

nervous system in, 669 

nystagmus in, 37 

occurrence of, 670 

pain in, 667 

percussion of chest in, 40 

prognosis of, 671 

in spasmus nutans, 670 

spinal deformity in, 665 

spine in, 45, 667 

spleen in, 669 

symptoms of, 664 

tarda, 670 

in tetany, 670 

thorax in, 664 

treatment of, 671-673 
Eale redux, 575 
Kectal enemata, somatose in, 107 

excreta in newborn, 166 

feeding in sick infants, 156 
Rectum, anatomy of, 506 

enemata of, 68 

exploration of, 42 

for appendicitis, 42 
for intussusception, 42 
for ischiorectal abscess, 42 
for tuberculous peritonitis, 42 

landmarks of, 506 

malformations of, 489 

polypus of, characters of, 508 
diagnosis of, 509 
location of, 508 
symptoms of, 508 
treatment of, 509 
Eecurrens spirillum in osteomyelitis, 730 
Keflex, Babinski, 46 

patellar, 46 



Reflex, Thomson's lip, 423 
Renal calculi, 746 
Resonance in normal chest, 561 
Respiration, 26 
artificial, 190 
diaphragmatic, 26 
character of, 26 
chemism of, 25 
in newborn, 157 
in rest, 35 
Respiratory murmur, character of nor- 
mal, 562 
system, diseases of, 527 
tract in sepsis neonatorum, 197 
Retinitis, absence of, in scarlet fever, 245 
Retro-oesophageal abscess, 446 
Retropharyngeal abscess, 534 

in acute follicular amygdalitis, 

539 
course of, 536 
diagnosis of, 536 
in diphtheria, 350 
etiology of, 534 
forms of, 535 
frequency of, 535 
inspiratory crowing in, 536 
position of head in, 36 
prognosis of, 537 
in scarlet fever, 236 
symptoms of, 536 
treatment of, 537 
lymphadenitis, 534 
Rheumatism, acute articular, 416 
etiology of, 416 
age, 417 
heredity, 416 
sexj 417 
prognosis of, 418 
symptoms of, 417 
choreic, 418 
endocarditic, 418 
treatment of, 418 
chorea in, 418, 792 
gonorrhceal, 419 
joints in, 43 
muscular, 420 
pneumonia in, 565 
Rheumatoid arthritis, 673 
Rhinitis, diphtheritic, 531 

Klebs-Loffler bacilli in, 531 
streptococcal form of, 531 
symptoms of, 531 
treatment of, 531 
Rhythmic movements of head, 800 
etiology of, 800 
nystagmus in, 800 
rachitis in, 800 
symptoms of, 800 
treatment of, 800 
Ridge's food, composition of, 112 
Ringworm of tongue, 441 
Robinson's groats, composition of, 112 
patent barley, composition of, 112 



878 



INDEX. 



Kobinson's patent barley, dextrinized, 148 

use of, 148 
Koger maladie, 641 
Eotch's method of infant-feeding, 125 
Eotheln, 254 

angina in, 254 

complications of, 257 

desquamation in, 255 

diagnosis of, 257 

difierentiated from measles, 270 

exanthemata, 255 

lymph-nodes in, 256 

spleen in, 256 

temperature in, 256 

treatment of, 257 
Bound worms, 510 

symptoms of, 510 
treatment of, 510 
Rubella. See Eotheln. 

SALTS in percentage feeding, 127 
Sarcoma of kidney, 755 
Scarlet fever, 231 

abscess of skin in, 238 
albuminuria in, 243 
amaurosis in, 244 
angina in, 233, 235, 236 
aphasia in, 244 
in arthritis, 242 
bacteriology of, 249 
blood in, 245 _ 
brain abscess in, 241 
chorea following, 246 
complicated by bronchopneu- 
monia, 245, 589 
convulsions in, 234 
course of, 234 
deaf-mutism in, 240 
deafness in, 240 
definition of, 231 
desquamation in, 239 
diagnosis of, from drug eruption, 
247 

from measles, 246 

from rotheln, 247 
differentiated from measles, 270 
diphtheria in, 236 
diphtheroid, 236 
ear in, 240 
eclampsia in, 244 
endocarditis in, 244, 642 
epidemics of, due to milk, 95 
etiology of, 231 
exanthema in, 234 , 237 
eye in, 241 
fever in, 234 
frequency of, 18 
gangrene of lung in, 245 
heart in, 244 

hydropericardium in, 243 
hydrothorax in, 243 
immunity to, 233 



Scarlet fever, intestines in, 245 

joints in, 242 

kidneys in, 243 

lobar pneumonia in, 245 

lungs in, 245 

lymph-nodes in, 241 

malignant cases of, 235 

mania in, 244 

mastoiditis in, 241 

mediastinal abscess in, 236 

melancholia in, 244 

meningitis in, 241 

morbid anatomy of, 248 

mouth in, 242 

nephritis in, 243 

without physical signs, 243 

nose in, 240 

occurrence of, 232 

CBdema of skin in, 243 

otitis in, 240, 246 

panophthalmitis in, 241 

pericarditis in, 245 

pleuritis in, 245 

prognosis of, 247 

retinitis in, 244 

retropharyngeal abscess in, 236 

septic cases of, 240 

sequelae of, 245 

sinus thrombosis in, 241 

stomach in, 245 

susceptibility to, 232 

symptoms of, 233 

tinnitus aurium in, 241 

tongue in, 237 

treatment of, 249 

ui-semia in, 244 

urine in, 243 
Schultze's method of artificial respira- 
tion, 189, 190 
Sclerema, 196 

adiposum, 219 

diagnosis of, 221 

morbid anatomy of, 220 

symptoms of, 220 

treatment of, 221 
in congenitally weak, 177 
in newborn, 217 
treatment of, incubatoi-s in, 181 
Scleroedema, 217 
etiology of, 217 
morbid anatomy of, 219 
symptoms of, 218 
treatment of, 219 
Scoliosis, 561 

deformity of chest in, 561 
Scorbutus, bone changes in, 723 
hsematuria in, 725 
infantile, 721 

deformities in, 724 

diagnosis of, 726 

duration of, 726 

ecchymosis in, 725 

etiology of, 722 



INDEX. 



879 



Scorbutus, infantile, fever in, 725 

fracture of bones in, 726 

gums in, 724 

hsematuria in, 725 

hemorrhages in, 724 
intestinal, 725 

history of, 721 

morbid anatomy of, 723 

nature of, 722 

occurrence of, 722 

pain in, 724 

paralysis in, 724 

prognosis of, 726 

pulse in, 726 

symptoms of, 723 

treatment of, 727 

urine in, 725 
Scott's oat flour, composition of, 112 
Scrofuloderma, 373 
Scrofulosis, 371 

bones in, 372, 375 
cornea in, 372 
course of, 376 
definition of, 371 
diagnosis of, 376 
ear in, 374 
ecthyma in, 373 
eczema in, 372 
etiology of, 371 
eye in, 374 
forms of, 371 
lichen scrofulosorum, 373 
lupus in, 373 
lymph-nodes in, 372-374 
mastoiditis in, 374 
ozsena in, 373 
prognosis of, 376 
treatment of, 376 
tuberculous, 372 

clinical picture in, 373 
Scrotum, anomalies of, 174 

congenital anomalies of, 174 

Scurvy, infantile, 721 

joints in, 43 

rickets, 721 

Sebaceous glands in skin of newborn, 163 

SebQiThoea, scalp, 843 

treatment of, 843 
Senses, development of, 32 
Sepsis in congenitally weak, 177 
due to ulcerations in mouth, 58 
neonatorum, blood-culture in, 198 

bones in, 197 

pneumonia in, 195 

respiratory tract in, 197 
in newborn, 194 

bacteria in, 195 

body-weight in, 197 

bones and joints in, 197 

circulatory system in, 197 

definition of, 195 

diagnosis of, 198 

etiology of, 195 



Sepsis in newborn, liver in, 197 
morbid anatomy of, 198 
nervous system in, 197 
prognosis of, 198 
respiratory tract in, 197 
retina in, 198 

sources of infection in, 95, 196 
symptoms of, 196 
treatment of, 198 
umbilicus in, 197 
urine in, 197 
vagina in, 197 
sudden death in, 172 
Septic peritonitis, boat-shaped abdomen 

in, 41 
Shrapnell's membrane, 736 
Sight, development of, 32, 37 
Sinus thrombosis in scarlet fever, 241 
Sitting, 33 
Skeleton growth, 73 
Skin, abscess of, in scarlet fever, 238 
care of, 57, 837 
diphtheria of, 353 
diseases of, 837 
examination of, 837 
forms of eruption of, 837 

of oedema of, 837 
hemorrhages into, in meningitis, 312 
in newborn, 163 

desquamation of, 163, 837 
jaundice of, 163 
lanugo of, 163 
milia of, 163 
perspiration of, 163 
vernix caseosa of, 163 
oedema of, in scarlet fever, 243 
Skull, bones of, syphilis of, 730 
tuberculosis of, 730 
brachycephalic, in cretinism, 689 
deformities of, 830 
Sleep, 54 

loss of, 55 
in open air, 56 
Smell, sense of, in newborn, 169 
Somatose, composition of, 106 
Soxhlet method of infant-feeding, 125 
Spasm of anus, 507 
of muscles, 45 
Spasmodic croup, 542 
Spasmus nutans, 800 

nystagmus in, 37 
Spastic walk, 47 
Speech, 33 
Spina bifida, 830 

course of, 833 
definition of, 831 
description of, 832 
diagnosis of, 834 
elliptical, 833 
forms of, 832 
lumbalis, 834 
occulta, 834 
symptoms of, 833 



880 



INDEX. 



Spinal cord, deformities of, 830 
Spine, 196, 432 

anatomy of, 43 
curvature of, in i-achitis, 665 
definition of, 432 

deformities of, in Potts' disease, 666 
deformity of, in rachitis, 665 
etiology of, 432 
examination of, 44 
in meningitis, 45 
in newborn, 43 
occurrence of, 432 
painful areas of, 44 
in Potts' disease, 45 
in rachitis, 45 
rigidity of, 44 
symptoms of, 433 
treatment of, 433 
Spitting, 127 

in bottle baby, 142 
in breast baby, 142 
treatment of, 142 
Spleen, amyloid, in bronchiectasis, 558 
anatomy of, 701 
cyst of, causing peritonitis, 522 
differentiation of, and kidney tumors, 

703 
disease of, 701 
enlargement of, 702 

in chylous ascites, 521 

in cirrhosis, 518 

in congenital obstruction of bile- 
ducts, 517 

in simple icterus, 517 

in syphilis, 518 
examination of, 701 
lesions of, in rachitis, 663 
palpation of, 702 
percussion of, 701 
puncture of, septic, 198 
in relapses of typhoid fever, 289 
tumors of, 703 

in fibrinous bronchitis, 550 
Sponge bath, 61 
Spoi-adic cretinism, 689 
Sprue, 196 

definition of, 432 
etiology of, 432 
occurrence of, 432 
symptoms of, 433 
treatment of, 433 
Standing, 33 
Staphylococcus albus in bacteriuria, 765 

in breast milk, 84 

in cystitis, 764 

in endocarditis, 642 

in gonorrhoeal peritonitis, 524 

in osteomyelitis, 730 

in otitis, 733 

in pneumonia, 565, 567 

in purpura, 718 

pyogenes aureus in breast milk, 
84 



Staphylococcus albus in pericarditis, 624 

in tonsillitis, 538 
Starch digestion in newborn, 162 
Status lymphaticus, 698 

sudden death in, 20 
symptoms of, 698 
treatment of, 700 
Steapsin, 453 

Stenosis of pulmonary artery, 638 
course of, 638 
physical signs of, 639 
pyloric, 467 
Sterilization, 97 

effect of, on milk, 98 
Sternomastoid, hsematoma of, 227 
Stethoscope, 37, 38 
Stomach, acids of, 451 
anatomy of, 449 
bacterial flora of, 452 
capacity of, 450 
digestion of, 451 
dilatation of, 465 
etiology of, 465 
physical signs of 466 
prognosis of, 466 
symptoms of, 465 
treatment of, 466 
dilated, constipation in, 465 
diseases of, 448 

classification of, 448 
motility of, 450 
position of, 449 
ulcers of, 466 
washing of, 65 
Stomatitis, aphthous, 434 

bacteriology of, 434 
course of, 435 
etiology of, 434 
symptoms of, 435 
treatment of, 435 
differentiated from diphtheria, 355 
in measles, 268 
pseudodiphtheritic, 438 
toxic, 434 

symptoms of, 435 
treatment of, 436 
ulcerative, 436 

etiology of, 436 

pseudodiphtheria bacilli in, 436 
spirochsetse in, 436 
treatment of, 436 
Stools, bacterial flora in, 456 
in bottle-fed infants, 455 
in breast-fed infants, 454 
characteristics of, 454 
composition of, 455 
number of, daily, 456 
reaction of, 456 
Strawberry tongue, 237 
Streptococcus in breast milk, 14 
in bronchopneumonia, 582 
in cows' milk, 95 
in cystitis, 764 



INDEX. 



881 



Streptococcus in diphtheritic rhinitis, 531 
pyogenes in endocarditis, 642 
in osteomyelitis, 730 
in pericarditis, 624 
in peritonitis, 521 
in pneumonia, 565 
in purpura, 718 
in retropharyngeal abscess, 535 
in tonsillitis, 538 
Stricture of oesophagus, congenital, 445 
Stridor, congenital laryngeal, 784 
causation of, 784 
symptoms of, 784 
Stridulous breathing in laryngitis, 543 
Submaxillary gland, secretion of, in new- 
born, 161 
Subphrenic abscess, 622 
diagnosis of, 623 
gas in, 622 

metallic tinkle in, 623 
physical signs of, 622 
succussion in, 623 
symptoms of, 622 
treatment of, 623 
Succussion in empyema, 614 
Sudamina, 845 
Sudden death, 20 
Sugar, fermentation of, 127 
milk-, 139 

percentage feeding, 127 
Sunburn, 56 
Suppurative meningitis, cerebro-spinal 

fluid in, 768 _ 

Suprarenal bodies, diseases of, 728 
Sydenham's chorea, 791 
Syphilis, 113, 401 
acquired, 401 

diagnosis of, 402 
etiology of, 401 
symptoms of, 402 
' of bones, 729, 408 
of skull, 730 
cause of prematurity, 176 
chylous ascites and, 521 
congenital, facial expression in, 36 
of nose, 527 
omphalorrhagia in, 206 
dentition in, 426 
differentiated from measles, 270 
enlargement of spleen in, 518 
hereditary, 405 

diagnosis of, 413 
prognosis of, 414 
morbid anatomy of, 406 
symptoms of, 403, 408 
treatment of, 412 
umbilical hemorrhage in, 206 
of intestine, 408 
joints in, 43 
of kidney, 408 
of larynx, 545 
of liver, 407, 518 
of lungs, 187 

56 



Syphilis of lungs cause of asphyxia neo- 
natorum, 187 

maternal nursing in, 114 

prematurity in, 176 

skin in, 407 

spleen in, 407 

sudden death in, 172 

of thymus gland, 698 

in wet-nurse, 113 
Syphilitic adenopathy, 685 

dactylitis, 412 
Syringomyelocele, 832 

TACHE cerebrale, 315 
Tachycardia in hysteria, 779 
Taenia elliptica, 511 

mediocanellata, 512 
solium, 510 

symptoms of, 512 
treatment of, 512 
Tapeworm, 511 
Taste, development of, 33 

in newborn, 168 
Taurocholic acid, 453 
Teeth, care of, 58 
Temperature, axillary, 52 
in bottle-fed infants, 28 
in breast-fed infants, 28 
course of, in twenty-four hours, 28 
in congenitally weak, 162 
during sleep, 28 
after exercise, 28 
after first bath, 28 
fluctuations of, 28, 78, 162 
method of taking, 52, 53 
in newborn, 162 
rectal, 52, 53 
Testis retention, treatment of, 174 
ectopia cruralis, 174 

perinealis, 174 
varieties of, 174 
Tetanus in newborn, 208 
diagnosis of, 210 
morbid anatomy of, 209 
symptoms of, 209 
treatment of, 210 
Tetany, 779 

Chvostek symptom of, 782 

definition of, 779 

duration of, 782 

etiology of, 780 

face in, 782 

forms of, 779 

frequency of, 779 

latent, 783 

muscular contractures in, 780 

occurrence of, 780 

position of extremities in, 780 

prognosis of, 783 

i^achitis in, 670 

relation of, to laryngospasm, 782 

symptoms of, 780 

treatment of, 783 $, 



882 



INDEX. 



Tetany, Trousseau phenomena of, 782 
Thermometer, use and disinfection of, 53 
Thomson's lip reflex, 423 
Thoracic duct, lesions of, in chylous 

ascites, 521 
Thread- worm, 511 
Thymic asthma, 698 
Thymus death, 20, 699 

lymphatism with, 700 
gland, abnormalities of, 697 
abscess of, 698 

changes in, in diphtheria, 698 
diseases of, 697 
hemorrhages into, 698 
hypertrophy of, 697 
inflammation of, 698 
landmarks of, 697 
large, sudden death in, 20, 698 
percussion of, 697 
syphilis of, 698 
tuberculosis of, 698 
weight of, 697 
Thyroid gland, diseases of, 688 
Tic, coprolalia in, 800 
deflnition of, 799 
ecolalia in, 800 
forms of, 799 
symptoms of, 799 
Tinnitus aurium in scarlet fever, 240 
Titubation, cerebellar, 47 
Tongue, congenital anomalies of, 440 
desquamation of, 442 
paralysis of, 191 
ringworm of, 441 
swelling of, 443 
ulceration of, in pertussis, 338 
Tongue-tie, 443 
Tonsillitis, follicular, 345 
lacunar, 538 
ulcero-membranous, 540 
character of, 541 
diagnosis of, 541 
from diphtheria, 541 
etiology of, 541 
frequency of, 540 
prognosis of, 542 
symptoms of, 541 
treatment of, 542 
Vincent bacillus in, 540 
Tonsils, anatomy of, 537 

an avenue of infection, 643 
diseases of, 537 
herpes of, 540 
in infectious diseases, 538 
Torticollis, 227 
Touch-sense in newborn, 169 
Toxins in endocarditis, 642 

in human milk, 88 
Trousseau symptom, 392 
Trypsin, 453 

Tubercle bacilli in cystitis, 764 
in human milk, 88 
in pericarditis, 624 



Tuberculosis, 377 
abdominal, 389 
after scarlet fever, 246 
bacillus of, 377 
of bones, 729 

of skull, 730 
of brain, 401 
in bronchiectasis, 558 
as cause of congenitally weak infants, 

176 
characteristics of, 379 
chylous ascites and, 521 
as contraindication to maternal nurs- 
ing, 114 
endocarditis in, 642 
etiologv of, 377 
foetal, 378 

of heart muscles, 388 
infected milk cause of, 96 
of joints, 43 
of kidney, 757 
of larynx, 388, 545 
maternal nursing in, 114 
meningitis, 389 
modes of infection in, 377 
of pericardium, 388 
of peritoneum, 383 

acute, 383 

chronic, 383 

course of, 387 

diagnosis of, 386 

etiology of, 384 

exploration in, 42 

forms of, 384 

morbid anatomy of, 384 

occurrence of, 383 

symptoms of, 385 

treatment of, 388 
of pleura, 388 
pulmonary, 380 

course of, 382 

diagnosis of, 383 

forms of, 380 

frequency of, 380 

localization of, 381 

morbid anatomy of, 380 

sputum in, 382 

symptoms of, 381 

temperature in, 382 

treatment of, 383 
of thymus gland, 698 
Tuberculous meningitis, 389 

abdomen boat-shaped in, 392 

Babinski reflex in, 393 

blood in, 317, 398 

cerebro-spinal fluid in, 768 

Cheyne-Stokes respiration in, 
392, 397 

Chvostek symptom of, 392 

differential diagnosis of, 400 

duration of, 400 

etiology of, 389 

facial expression in, 36 



INDEX. 



883 



Tuberculous meningitis, facial paralysis 
in, 393 

Kernig's symptom of, 392, 397 

lumbar puncture in, 399 

Macewen's sign in, 398 

morbid anatomy of, 390 

occurrence of, 389 

onset of, 391, 396 

prognosis of, 401 

symptoms of, 391 

tache cerebrale, 392 

treatment of, 401 
peritonitis differentiated from acute 
appendicitis, 504 
Tumors, adenoid, of umbilicus, 201 
of larain, 807 
cerebellar, gait in, 47 
of kidney, 703, 754 
ovarian, rectal exploration for, 42 
of spleen, 703 
Tympanites, 464 

in appendicitis, 502, 504 
in gastro-enteritis, 41 
in peritonitis, 522 
in pneumonia, 41 

treatment of, 581 
in rachitis, 41 
treatment of, 464 
Tympany over subphrenic abscess, 622 
Tvphoid bacilli in human milk, 88 
fever, 281 

amblyopia in, 290 

aphasia in, 290 

in arthritis, 290 

blood in, 289-292 

bronchitis in, 290 

bronchopneumonia in, 588 

cholecystitis in, 288 

complicated by bronchopneu- 
monia, 290, 588 

complications of, 289 

constipation in, 298 

cystitis in, 764 

diagnosis of, 293 

differentiated from measles, 270 

diphtheria in, 290 

duration of, 293 

Ehrlich diazo-reaction in, 294 

endocarditis in, 642 

enter oclvsis in, 68 

foetal, 282 

forms of, 293 

gangrene of lung in, 290 

infantile, 282 

infected milk cause of, 95 

intestinal perforation in, 291, 297 
frequency of, 291 
symptoms of, 291, 292 
time of, 291 
treatment of, 297 

Kernig's symptom in, 46 

mastoiditis in, 288, 738 

melancholia in, 290 



Typhoid fever, modes of onset, 283, 284 

morbid anatomy of, 282 

mumps complicating, 333 

myocarditis in, 289 

occurrence of, 281 

onychia in, 289 

otitis in, 288 

parotitis in, 288 

pneumonia in, 289, 565 

prognosis of, 293, 295 

relapses of, 285-289 

roseola in, 285 

spleen in, 285 

symptoms of, 283 

temperature in, 297 

treatment of, 296 

bran bath in, 297 

Widal reaction in, 294 
Typhus fever, pneumonia in, 565 

ULCEE, corneal, photophobia in, 37 
dysenteric, causing peritonitis, 522 
of stomach, 466 

causing peritonitis, 522 
typhoidal, causing peritonitis, 522 
of umbilicus, 201 
Umbilical arteries, 159 
cord, dressing for, 49 
gangrene of, 49 
granuloma of, 49 
in premature infants, 49 
stump of, 49 
time of falling off of, 49 
tying of, 48 
hemorrhage in Buhl's disease, 206 
hernia, 207 
infection, 195 
Umbilicus, adenoid tumors of, 201 
blennorrhoea of, 201 
diseases of, 202 
enteratoma of, 200 
fungus of, 200 
gangrene of, 202 
granuloma of, 200 
hemorrhage of, 206 
infectious, 195 
omphalitis of, 199 
perfoiution at, in peritonitis, 525 
phlegmon of, 201 
in sepsis, 196 
ulcer of, 201 
Uraemia in scarlet fever, 244 
Urea, 77 

Urethritis in male child, 763 
Uric acid infarction, 32 

of kidney, 32 
in newborn, 166 
Urination, frequency of, 29 
Urine, acetone in, 31 
albumin in, 31, 166 
in bottle-fed infants, 165 
in breast-fed infants, 165 
brick-dust deposit in, 746 



S84 



INDEX. 



Urine, casts in, 32 

in cholera infantum, 474 
in chorea, 794 
dextrose in, 32 
in diabetes, 681 
diacetic acid in, 31 
in hsematuria, 744 
indican in, 31 

artificially fed infants, 31 

breast-fed infants, 31 

gastro-enteritis of, 31 

suppuration of, 31 

tuberculosis of, 31 
in infantile scorbutus, 725 
in mumps, 333 
in newborn, 29, 164 
of newborn, albumin in, 166 

casts in, 32 

specific gravity of, 29, 165 
odor of, 29 

physical characteristics of, 29 
quantity of, estimation of, 35 
red, 35 

in scarlet fever, 243 
in sepsis neonatorum, 197 
specific gravity of, 165 
urea in, 30 
urobilin in, 31 
yellow, 35 
Urobacillus liquefaciens, 764 
Urogenital blennorrhoea, 760 

infections, 196 
Uterine apnoea, ,157 
Uvula, malformations of, 443 

VACCINATE, age^at which to, 278 
Vaccination, 277 

animal lymph in, 278 
complications of, 279 
course of, 279 
eruptions in, 280 
humanized vaccine in, 278 
management of, 280 
mode of, 278 
osteomyelitis due to, 280 
revaccination, 281 
suppuration of joints due to, 280 
Valentine's beef-juice, composition of, 106 
Valvular disease of heart, chronic, 650 
Varicella, 273 

affection of joints in, 276 
complications of, 275 

bronchopneumonia, 589 
mumps, 333 
definition of, 273 
diagnosis of, 277 
immunity to, 273 
incubation of, 274 
otitis in, 276 
prognosis of, 277 
symptoms of, 274 
treatment of, 277 
Vegetations, adenoid, 533 



Veins, abdominal, distention of, in perito- 
nitis, 525 
Vejo's beef-extract, composition of, 108 
Venous hum, 656 

Ventricular septum, cyanosis in, 641 
defects of, 641 
murmur in, signs of, 641 
Vermiform appendix, anatomy of, 501 
palpation of, 501 
situation of, in children, 501 
size of, 501 
Vernix caseosa, 50, 163 
Vincent bacillus, 541 
Vision, defective, position of head in, 35 
Vomiting in appendicitis, 462 
in bottle babies, 144 
cyclic, 458 

acetone breath in, 460 
constipation in, 459 
definition of, 458 
diagnosis of, 460 
etiology of, 459 
symptoms of, 459 
treatment of, 461 
habitual, of infants, 458 
in infectious diseases, 463 
in intestinal obstru 
in meningitis, 463 
from over-feeding in breast-fed in- 
fants, 122 
from overflow . in breast-fed infants, 

122 
in pyloric stenosis, 462, 467 
in tumors of brain, 463, 808 
Von Jaksch's ansemia, 686, 708 
Vulva, diphtheria of, 353 
Vulvo-vaginitis, 760 
arthritis in, 762 
complications of, 762 
cystitis in, 764 
definition of, 760 
etiology of, 761 
gonococcus in, 761 
peritonitis in, 762 
symptoms of, 762 
treatment of, 763 

WALK, spastic, 47 
Walking, 33 
Water, amount of, in breast milk, 72, 83 

barley, 104 

excretion of, 78 
Weaning, 151 

cereals used in, 110 
Weight, average newborn, 21 

Bowditch's tables of, 26 

chart of, 23 

in congenitally weak, 178 

daily gain in, 21 

increase of, in bottle-fed infants, 78 
in breast-fed infants, 78 

loss of, during first day, 29 

normal, first ten days, 21 



INDEX. 



885 



Weight, physiological loss of, 170 
Wet-nurse, age of, 115 

baby of, 115 

breast of, 115 

milk of, quality of, 116 
quantity of, 116 

nipples of, 115 

period of lactation of, 115 

physical examination of, 116 

selection of, 115 
Wet-nursing, arguments against indis- 
criminate use of, 113 

dyscrasias transmitted by, 113 
Whey, artificial feeding with, 145 

composition of, 145 

prepai-ation of, 146 
formulae for, 147 



Widal reaction, 294 

in typhoid fever, 294 
Winckel's disease, 195, 216 
diagnosis of, 217 
etiology of, 216 
hemorrhage in, 212 
morbid anatomy of, 216 
symptoms of, 216 
treatment of, 217 
Witches' milk, 164 
Woodward's method of proteid analysis, 

92 
Worms, intestinal, 509 
pin-, 510 
round, 510 
tape-, 511, 512 
thread-, 511 



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